COLLEGE  OF   OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS   •  LOS  ANGELES,  CALIFORNIA 


THE 

SURGICAL  DISEASES 
OF  CHILDREN 


•      THE^XjnB 
[SURGICAL  DISEASES 

OF  CHILDREN7 


WILLIAM   FRANCIS   CAMPBELL,  A.B.,   M.D. 

PBOFESSOB     OF     ANATOMY,     LONG      ISLAND      COLLEGE      HOSPITAL;       SURGEON-IN-CHIEF      TRINITY      HOSPITAL; 

ATTENDING   SURGEON,    METHODIST    EPISCOPAL   HOSPITAL;     CONSULTING    SURGEON, 

CONEY    ISLAND,    SWEDISH   AND  JAMAICA    HOSPITALS, 


AND 

LE  GRAND   KERR,  M.D. 

ATTENDING  PEDIATHIST  TO  THE  METHODIST  EPISCOPAL,  WILLIAMSBURGH,  BUSHWICK  AND  SWEDISH 

HOSPITALS;  CONSULTING  PEDIATRIST  TO  THE  INDUSTRIAL  HOME  FOR  CHILDREN 

AND  THE  ROCKAWAY  BEACH  HOSPITAL. 


NEW  YORK  AND  LONDON 

D.  APPLETON   AND   COMPANY 

1912 


•  ^ 


COPYRIGHT,  1912,  BY 
D.  APPLETON  AND  COMPANY 


Printed  in 

New  York,  U.  S.  A. 


UPON    WHOSE    CONSCIENTIOUS 

CARE    AND    DEVOTION    TO    HUMAN 

WELFARE    DEPENDS    THE    EFFICIENCY 

OF    FUTURE    MEN    AND    WOMEN 

THIS  BOOK  IS  DEDICATED 


PREFACE 

The  child  is  an  unfinished  product.  Childhood  is  the  period 
when  Nature,  through  physiological  processes  peculiarly  active,  en- 
deavors to  bring  the  individual  to  completeness,  and  thus  preserve 
the  species. 

This  phenomenon  of  growth  implies  more  active,  more  rapid, 
more  constant  cellular  changes.  It  necessitates  greater  nutritional 
demands,  and  leaves  little  vital  capital  in  reserve  for  contingencies. 

Thus,  while  the  child's  organism  is  more  plastic,  it  is  less  stable ; 
while  it  heals  rapidly,  it  devitalizes  easily.  With  constructive  sur- 
gery it  is  a  walling  ally,  to  destructive  procedures  it  is  intolerant. 

The  surgery  of  childhood  therefore  imposes  a  problem  peculiarly 
difficult,  not  merely  because  of  the  smaller  anatomical  relationships, 
but  because  the  surgeon  is  dealing  with  an  organism  singularly  com- 
plex in  which  the  surgical  disease  is  ever  interwoven  with  problems 
of  nutrition,  development,  and  future  efficiency. 

Modern  surgery,  with  its  perfection  of  technique,  is  adequate 
only  as  it  can  adapt  itself  to  the  peculiar  demands  of  the  child's  or- 
ganism. The  surgeon  is  efficient  only  as  he  possesses  a  correct 
appreciation  of  surgical  diseases  as  they  affect  the  child. 

The  authors  therefore  feel  that  a  distinct  advance  in  this  field  is 
possible  only  as  the  surgical  diseases  of  childhood  are  viewed  from 
both  the  standpoints  of  the  Surgeon  and  the  Pecliatrist.  Again,  the 
surgery  of  childhood  imposes  a  heavy  responsibility  upon  the  family 
physician — it  is  always  his  problem  first,  before  it  is  shifted  to  the 
shoulders  of  the  specialist;  upon  his  prompt  recognition  of  the  sur- 
gical disorder,  and  his  adequate  appreciation  of  the  proper  treatment, 
the  future  welfare  of  the  child  depends. 

A  deformity  can  often  be  corrected  in  early  life  which  later  is 
accompanied  by  secondary  changes  which  can  never  be  corrected. 

A  crippled  child  is  often  a  neglected  child. 

There  will  be  fewer  cripples  in  the  world  when  the  physician  is 
more  alert  to  the  importance  of  the  early  recognition  of  disease  and 
its  timely  treatment. 

In  those  congenital  deformities  and  chronic  diseases  connected 
with  the  locomotor  apparatus  the  authors  have  endeavored  to  em- 


PREFACE 

phasize  the  importance  of  early  diagnosis,  the  treatment  is  merely 
suggestive;  and  it  is  urged  that  the  advantages  of  the  orthopedic 
clinic  be  sought,  and  the  experience  and  skill  of  the  orthopedic 
surgeon  be  secured. 

It  is  not  the  profound  knowledge  of  the  specialist  that  is  needed 
so  much  as  a  sound  practical  knowledge  of  surgery  and  the  child, 
and  a  deep  sense  of  the  responsible  part  which  the  physician  plays 
in  the  welfare  of  the  future  men  and  women. 

The  authors  present  this  volume  as  a  practical  guide  to  the  family 
physician  that  he  may  render  a  better  service  to  his  patient. 

The  interests  of  the  patient  are  best  conserved  when  there  is  a 
practical  appreciation  of  the  fact  that  in  the  treatment  of  surgical 
diseases  the  physician  and  surgeon  each  play  an  important  role — the 
role  of  cooperation ;  each  bears  an  equal  responsibility,  and  each  con- 
tributes his  share  to  the  favorable  or  unfavorable  result. 

The  works  of  many  authors  who  have  contributed  their  expe- 
rience have  been  consulted  and  freely  quoted,  due  acknowledgment  of 
which  has  been  noted  in  the  text. 

We  desire  to  express  our  appreciation  of  the  work  of  Mr.  F.  A. 
Deck,  whose  efficient  cooperation  in  making  the  illustrations  has 
materially  enhanced  the  value  of  the  text. 

WILLIAM   FRANCIS    CAMPBELL, 
LEGRAND  KERR. 

BROOKLYN,  NEW  YORK. 


CONTENTS 

PART    I 
GENERAL   SURGERY 

SECTION   I 
GENERAL    CONSIDERATIONS 

CHAPTER  PAGE 

I.     QUALIFICATIONS  OP  THE  PEDIATBTC  SURGEON       .        .  3-4 

II.     THE  EXPRESSION  OF  DISEASE  IN  THE  YOUNG  CHILD    .  4-9 

SECTION  II 
EXAMINATION 

III.  THE  EXAMINATION 10-21 

General  considerations — What  is  the  age? — General 
history  taking — Securing  child's  confidence. 

IV.  GENERAL  POSTURE 21-24 

Side  position — Dorsal  position — On  the  abdomen — 
Forced  positions — Upright  position — Constantly 
changed  position. 

V.     THE  GAIT 24-26 

Limping — Waddling — Stumbling  gait. 

VI.     PAIN 26-46 

General  considerations :  Tenderness ;  Mode  of  Onset ; 
Time  of  occurrence;  Character  of  pain;  Site  of 
pain — The  surgical  significance  of  pain :  Abdominal 
pain;  Headache;  Earache;  Painful  defecation; 
Painful  urination. 

VII.  THE  EXAMINATION  OF  THE  BLOOD  ....  46-55 
General  considerations :  Method  of  obtaining  the 
specimen;  Examination  of  the  fresh  specimen;  The 
blood  count;  The  color  index — Abnormal  conditions 
of  the  blood:  Leukocytosis ;  Leukopenia;  Eosino- 
philia ;  Lymphocytosis. 

VIII.     THE  DIAGNOSTIC  VALUE  OF  THE  X-RAY        .        »        .        55-56 

ix 


CONTENTS 

SECTION  III 
ANESTHETIZATION 

[AFTER  PAGE 

IX.      ANKSTIIKMA .         .         .         57-66 

General  considerations:  Preparation  of  the  child; 
Conditions  to  be  watched  by  the  anesthetist;  Selec- 
tion of  the  anesthetic — Varieties  of  anesthetics: 
Ether;  Chloroform;  Nitrous  oxid;  Nitrous-oxygen- 
ether;  Nitrous-ether;  Ethyl  chlorid. 

X.     POST-ANESTHETIC  CARE 66-69 

Nausea  and  vomiting — Hematemesis — Undue  rest- 
lessness— Sweating — Thirst. 

XL     SEQUELAE  OF  ANESTHESIA 69-71 

Conjunctivitis — Soreness  of  the  jaw — Soreness  of 
the  tongue — Paralysis — Burns — Pneumonia. 

XII.     LOCAL  ANESTHESIA 71-73 

Cold,  freezing — Infiltration. 


SECTION  IV 
THE  OPERATION 

XIII.  PREPARATION  FOR  THE  OPERATION        ....        74-84 

Preparation  of  the  patient :  Physical  condition ; 
Urine;  Blood;  Laxative;  Digestive  disturbances; 
Water  drinking;  Bathing;  Toilet  of  mouth — Prepa- 
ration of  the  field  of  operation — Examination  of  pa- 
tient: Examination  of  the  heart;  Examination  of  the 
chest;  Examination  of  the  urine. 

XIV.  THE  CONTROL  OF  HEMORRHAGE 84-88 

Primary  hemorrhage;  Delayed  hemorrhage — Sec- 
ondary hemorrhage;  Constitutional  treatment  of 
hemorrhage. 

XV.     POST-OPERATIVE  CARE 88-95 

The  room — Diet  after  operation — The  bowel  func- 
tion— Vomiting — Care  of  the  wound. 


CONTENTS  xi 

CHAPTER  PAGE 

XVI.     THIRST:  ITS  SIGNIFICANCE  AND  RELIEF      .        .        .        95-97 

XVII.     PAIN  AND  SLEEP  .        ; 97-99 

XVIII.     THE  GENERAL  MANAGEMENT  OF  POST-OPERATIVE  CON- 
VALESCENCE      99-101 

Fresh  air  and  sunshine. 

XIX.     GAVAGE,  LAVAGE,  AND  RECTAL  FEEDING       .        .        .    101-106 
Gavage — Nasal  feeding — Lavage — Rectal  feeding. 

XX.     SHOCK 106-111 

Diagnosis — Etiology — Treatment  of  shock. 

SECTION  V 
CONSTITUTIONAL  AFFECTIONS  WITH  A  SURGICAL  ASPECT 

XXI.     HEMOPHILIA  . 112-115 

Etiology  —  Pathology  —  Symptomatology  —  Diag- 
nosis— Prognosis — Treatment. 

XXII.     RACHITIS 115-130 

Etiology — Age  incidence — Symptoms — Diagnosis — 
Treatment. 

XXIII.  SCORBUTUS 130-138 

Age  incidence  —  Etiology — Pathology — Symptoma- 
tology —  Diagnosis  —  Prognosis  —  Prophylaxis  and 
treatment. 

XXIV.  SYPHILIS 138-155 

Acquired  syphilis — Congenital  syphilis :  Types  of 
disease;  Pathology;  Symptoms;  Diagnosis;  Prog- 
nosis; Treatment. 

XXV.  STATUS  LYMPHATICUS 155-158 

Pathology — Symptoms — Diagnosis. 

SECTION  VI 
INFECTIOUS  DISEASES 

XXVI.     ADENITIS 159-174 

Simple  acute  adenitis:  Etiology;  The  lesions; 
Symptomatology ;  Diagnosis ;  Treatment — Simple 


Jii 


CONTENTS 


chronic  adenitis:  Symptoms;  Diagnosis;  Treatment 
— Syphilitic  adenitis — Tuberculous  adenitis:  Etiol- 
ogy; Lesions;  Symptoms;  Diagnosis;  Prognosis; 
Treatment. 


XXVII.     OSTEOMYELITIS 


Infective  osteomyelitis:  Etiology  and  pathology; 
Symptoms;  Diagnosis;  Prognosis;  Treatment — 
Rarer  forms  of  osteomyelitis;  Periostitis  albumi- 
nosa;  Primary  chronic  osteomyelitis. 


XXVIII.     TUBERCULOSIS 


XXIX. 


XXX. 


Surgical  tuberculosis:  Etiology;  Clinical  manifesta- 
tions in  children  and  adults;  Clinical  diagnosis  of 
tuberculosis;  General  principles  of  surgical  treat- 
ment; Treatment  of  surgical  tuberculosis — Tuber- 
culosis of  bones  and  joints;  Tuberculosis  of  bones; 
Tuberculosis  of  joints. 

ERYSIPELAS 

Etiology  —  Incubation  —  Symptoms  —  Diagnosis 
— Prognosis — Treatment. 

TETANUS        

Etiology :  Bacillus  tetani — Clinical  forms — Symp- 
tomatology and  diagnosis — Prognosis — Treatment. 


174-183 


184-208 


208-214 


214-226 


XXXI.     SEPTIC  DISEASES 226-235 

Septic  diseases  in  general  septic  intoxication : 
Symptoms  —  Septicemia :  Symptoms ;  Prognosis ; 
Treatment — Pyemia:  Etiology;  Symptoms;  Com- 
plications; Diagnosis;  Treatment — Sapremia:  Eti- 
ology; Treatment — Purulent  infections  of  the  skin 
and  subcutaneous  tissues. 


XXXII.     BACTERIAL  VACCINES 


.    235-236 


SECTION  VII 
INJURIES 

XXXIII.     BURNS  AND  SCALDS 

Results — Diagnosis — Prognosis — Treatment. 


.     237-246 


CONTENTS 


Xlll 


CHAPTER 

XXXIV. 


FRACTURES  IN  CHILDREN 

Peculiarities  of  fracture  in  children ;  Fractures  of 
the  newly  born ;  Incomplete  or  greenstick  fractures ; 
Separation  of  the  epiphyses;  Exuberant  callus; 

.  Fracture  fever — Intrapartum  fractures :  Fracture 
of  the  humerus ;  Fracture  of  the  clavicle ;  Fracture 
of  the  femur — Traumatic  separation  of  the  epi- 
physes :  Separation  of  the  upper  epiphysis  of  the 
humerus;  Separation  of  the  lower  epiphysis  of  the 
humerus;  Separation  of  the  lower  epiphysis  of  the 
tibia;  Separation  of  the  upper  epiphysis  of  the 
tibia. 


PAGE 

246-258 


SECTION  VIII 
SURGICAL  DISEASES  OF  THE  CENTRAL  NERVOUS   SYSTEM 

XXXV.     INJURY  AND  DISEASE  OF  THE  SPINAL  CORD  AS   EVI- 
DENCED BY  SYMPTOMS  ......    259-267 

Paralysis:  Corticospinal  paralysis;  Spinomuscular 
paralysis;  General  character  of  paralysis  following 
injury  or  disease  of  the  spinal  cord — Disturbances 
of  anal  and  vesical  sphincter  control — Ataxia : 
Babinski's  sign ;  Sensory  disturbances — Disturbances 
of  sensation — Pain — Vasomotor  and  trophic  dis- 
turbances. 

XXXVI.     NATURE  OP  INJURIES  OF  THE  SPINAL  CORD  .        .        .    268-270 
Spinal  concussion — Contusion  and  laceration  of  the 
cord — Mode  of  production  of  injuries  to  the  spinal 
cord. 


XXXVII.     LUMBAR  PUNCTURE       .        .  .  .     270-277 

XXXVIII.  INJURIES  OF  THE  BRAIN  AND  ITS  MEMBRANES  .  .  277-284 
Symptoms:  Cerebral  vomiting;  Headache;  Convul- 
sions; Paralysis;  Muscular  contraction — Concussion 
of  the  brain:  Symptoms;  Prognosis;  Diagnosis; 
Treatment — Compression  of  the  brain:  Symptoms; 
Prognosis — Contusion,  laceration,  and  wounds  of 
the  brain :  Symptoms ;  Diagnosis. 

XXXIX.     THROMBOSIS  OF  THE  SINUSES  OF  THE  DURA  MATER      .    284-287 
Etiology — Site — Symptoms — Course   and   prognosis 
— Treatment. 


xiv  CONTENTS 

CHAPTER  PAGE 

XL.     CEREBRAL  ABSCESS 287-292 

Etiology  —  Symptoms  —  Diagnosis  —  Prognosis  — 
Treatment. 


XLI. 


XLIL 


INTRACRANIAL  TUMORS 

Etiology — Symptoms — Diagnosis. 


.     292-297 


THE  PARALYSIS  OF  CHILDHOOD     .      ,  ^        . 

Acute  poliomyelitis:  The  age  incidence;  The  sea- 
sonal incidence;  Symptoms;  Diagnosis;  Mechanical 
and  operative  treatment — Erb's  paralysis :  Etiology ; 
Pathology;  Diagnosis;  Prognosis;  Treatment — In- 
fantile cerebral  paralysis:  The  prenatal  group;  The 
natal  group;  The  postnatal  group — Pressure  paral- 
ysis— Musculospiral  nerve  paralysis — Facial  paral- 
ysis— Sympathetic  nerve  paralysis. 


298-319 


SECTION  IX 


NEOPLASMS 


XLIIL     TUMORS  IN  CHILDREN 

General  consideration  of  tumors — The  transforma- 
tion of  benign  into  malignant  tumors — Varieties  of 
tumors :  Fibromata ;  Myxomata ;  Lipoma ;  Bone 
tumors;  Chondromata;  Osteomata;  Myomata;  Neu- 
romata; Lymphoma;  Sarcoma;  Carcinoma;  Terato- 
mata;  Angioma;  Lymphangioma;  Cystoma;  Reten- 
tion cysts;  Dermoids;  Keloid. 


320-350 


THE  HEAD  AND  NECK 

XLIV.     AFFECTIONS  or  THE  HEAD    ...... 

Congenital  affections:  Encephalocele;  Microcepha- 
lus;  Congenital  hydrocephalus ;  Cephalhematoma — 
Fractures  of  the  skull ;  Dermoid  cysts  of  the  head. 


353-362 


CONTENTS 

CHAPTEB 

XLV.     AFFECTIONS  OF  THE  EAR 

Malformation  of  the  external  ear- 
in  the  ear — Middle  ear  disease. 


XV 

PAGE 

302-364 


-Foreign  bodies 


XLVI.     FACE   AFFECTIONS 364-370 

Vascular  nevus :  Varieties ;  Diagnosis ;  Prognosis ; 
Treatment — Lymphangiomas  of  the  face :  Lyinph- 
angioma  of  the  eyelids;  Lymphangioma  of  the  lips 
— Dermoid  cysts  of  the  face:  Diagnosis;  Treatment. 

XLVII.     ORAL   AFFECTIONS 370-387 

Foreign  bodies  in  the  nose — Harelip:  Clinical  pic- 
ture; Prognosis;  Operation;  After-treatment — Cleft 
palate :  Etiology  and  pathology ;  Treatment ;  Af  ter- 

-  treatment — Ranula  :    Varieties;    Treatment — Hyper- 

trophied  tonsils — Adenoid  vegetations — Retrophar- 
yngeal  abscess:  Etiology;  Symptoms;  Diagnosis; 
Prognosis ;  Treatment. 

XL VIII.     THE  AIR  PASSAGES 387-395 

Foreign  bodies  in  the  air  passages:  Symptoms; 
Diagnosis ;  Prognosis ;  Treatment  -  -  Intubation : 
Preparation  of  the  operator;  Preparation  of  the 
patient;  The  Operation;  After-treatment;  Re- 
moval of  the  tube — Tracheotomy:  Anatomical 
points;  Operation;  After-treatment. 

XLIX.     THE  NECK 396-409 

Congenital  torticollis:  Etiology;  Pathology;  Symp- 
toms; Diagnosis;  Treatment — Tuberculous  glands 
of  the  neck :  Anatomical  considerations ;  Method 
of  invasion;  Symptoms;  Diagnosis;  Treatment — 
Bronchial  fistula?:  Clinical  characteristics;  Treat- 
ment— Bronchial  fibro-chondromata  :  Treatment — 
Congenital  cysts  of  the  neck:  Lymphatic  cysts; 
Bronchial  cysts — Dermoid  cysts  of  the  neck — Lipo- 
mas,  of  the  face  and  neck. 

L.     THE  ESOPHAGUS    .        . 409-414 

Malformation  of  the  esophagus :  Varieties ;  Symp- 
toms; Treatment — Congenital  stenosis  of  the  esoph- 
agus— Foreign  bodies  in  the  pharynx  and  esopha- 
gus: Anatomical  peculiarities;  Symptoms;  Treat- 
ment— Cicatricial  stenosis  of  the  esophagus :  Clinical 
course;  Diagnosis;  Treatment. 


XVI 


CONTENTS 


CHAPTER 

LI. 


PAGE 

415-426 


SECTION  XI 
THORAX  AND  SPINE 

CONGENITAL  AFFECTIONS  OF  THE  THORAX  AND  SPINE  . 
Malformation  of  the  thorax:  Absence  of  the  ster- 
num; Cleft  sternum;  Pigeon  breast; "Funnel  chest — 
Supernumerary  cervical  ribs — Spinal  Bifida :  Loca- 
tion ;  Anatomical  classification ;  'Symptoms ;  Diag- 
nosis; Prognosis;  Treatment — Congenital  sacrococ- 
cygeal  tumors;  Etiology  and  pathology;  Situation; 
Symptoms;  Diagnosis;  Treatment — Paracoccygeal 
fistulas — Congenital  diaphragmatic  hernia :  Loca- 
tion ;  Symptoms ;  Treatment — Congenital  hernia  of 
the  lung. 


LII.     EMPYEMA      .        .        .        .        ...        .        .    426-429 

Special  features  of  symptoms — Diagnosis — Prog- 
nosis— Treatment — After-treatment — Bilateral  em- 
pyema. 

LIIL     CURVATURE  OF  THE  SPINE 429-446 

The  normal  evolution  of  the  spinal  column — Ab- 
normal positions  of  spinal  column :  Kyphosis ; 
Lordosis;  Scoliosis. 

LIV.     TUBERCULOSIS  OF  THE  SPINE 446-465 

Clinical  picture — Symptoms — Diagnosis — Differen- 
tial diagnosis  —  Prognosis  —  Treatment  —  Tubercu- 
losis of  the  sacroiliac  joint. 


SECTION  XII 
ABDOMEN  AND  PELVIS 

LV.     CONGENITAL  AFFECTIONS  OF  THE  ABDOMEN  .        .        .    466-470 
Meckel's  diverticulum :  Clinical  anatomy ;  Diagnosis ; 
Treatment — Malformations    of    the    urachus :    Uri- 
nary fistula?  of  the  umbilicus ;  Cysts  of  the  urachus. 

LVI.     HERNIA 470-489 

rmbilical    hernia:    Pathology;    Symptoms;    Treat- 
ment— Inguinal    hernia:    Normal    and    pathological 


CONTENTS 


xvii 


anatomy;  Frequency;  Etiology;  Site;  Pathology; 
Symptoms;  Differential  diagnosis;  Complications; 
Treatment — Femoral  or  crural  hernia. 

LVII.     EXSTROPHY  OF  THE  BLADDER 489-492 

LVIII.     CONGENITAL  HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS    492-494 
Normal    and    pathological    anatomy — Occurrence — 
Symptoms — Treatment. 


LIX.     PERITONITIS 

Tuberculous  peritonitis:  Clinical  forms;  Symptoms; 
Diagnosis ;  Treatment — Pnemnococcus  peritonitis : 
Clinical  forms;  Symptoms;  Diagnosis;  Treatment. 

"LX.     APPENDICITIS 

Anatomy — Etiology  and  Pathology — Symptoms — 
Diagnosis — Prognosis — Treatment. 


499-512 


LXI.     INTESTINAL  DISORDERS 

Intussusception  :  Symptoms ;  Diagnosis ;  Prognosis ; 
Treatment — Congenital  idiopathic  dilatation  of  the 
colon :  Symptoms ;  Treatment. 


512-517 


LXII.  DISEASES  OF  THE  ANUS  AND  RECTUM  .... 
Imperf orate  anus  and  rectum :  Clinical  picture ; 
Treatment — Prolapse  of  the  rectum:  Symptoms; 
Diagnosis;  Prognosis;  Treatment — Polypus  of 
rectum;  Etiology;  Symptoms;  Diagnosis;  Treat- 
ment— Fissure  of  the  anus:  Symptoms;  Treatment 
— Perianal  abscess:  Symptoms;  Treatment. 


517-528 


LXIIL     SARCOMA  OF  THE  KIDNEY 

Diagnosis — Prognosis — Treatment. 


528-529 


LXIV.     BLADDER  DISEASES 


Enuresis,  incontinence  of  urine:  Symptoms;  Diag- 
nosis; Treatment — Vesical  calculi:  Etiology;  Symp- 
toms; Diagnosis;  Treatment — Tremors  of  the  blad- 
der: Symptoms;  Treatment. 


529-534 


LXV.     PHIMOSIS  AND  PARAPHIMOSIS       .        ..... 

Phimosis :     Clinical    course ;     Treatment — Paraphi- 
mosis:  Treatment. 


535-538 


xvm 


CONTENTS 


LXVI.     DISEASES  OP  THE  TESTIS 539-549 

Hydrocele:  Normal  and  pathological  anatomy;  va- 
rieties; Symptoms;  Diagnosis;  Treatment — Unde- 
scended  and  misplaced  testicle:  Undeseended  tes- 
ticle; Misplaced  testicle;  Complications;  Prognosis; 
Symptoms ;  Treatment — Tuberculosis  of  the  testicle : 
Clinical  picture;  Diagnosis;  Treatment — Sarcoma  of 
the  testicle:  Treatment. 

LXVIL     EPISPADIAS  AND  HYPOSPADIAS  '.  549-559 

Epispadias:  Pathology;  Symptoms;  Treatment — 
Hypospadias :  Pathology ;  Clinical  varieties ;  Func- 
tional disturbances;  Treatment. 

LXVIII.     MALFORMATIONS  OF  THE  FEMALE  GENITALS..  559-560 


SECTION  XIII 
THE  UPPER  EXTREMITY 

LXIX.     CONGENITAL  MALFORMATIONS  OF  THE  EXTREMITIES      .    561-562 
Absence    of    extremities:    Ectromely;    Phocomely; 
Etiology;  Treatment — Congenital  grooves. 

LXX.     THE  SHOULDER 562-567 

Congenital  elevation  of  the  scapula :  Clinical  pic- 
ture; Etiology;  Treatment — Fracture  of  the  clavicle: 
Symptoms;  Treatment — Congenital  dislocation  of 
the  shoulder — Tuberculosis  of  the  shoulder:  Symp- 
toms; Diagnosis;  Prognosis;  Treatment. 

LXXI.     THE  ELBOW 567-590 

Congenital  dislocation  of  the  elbow — Tuberculosis 
of  the  elbow:  Symptoms;  Diagnosis;  Treatment — 
Fracture  at  the  elbow :  Anatomy  of  the  elbow ; 
Diagnosis;  Prognosis;  Typical  forms  of  fracture  of 
the  elbow  in  children;  Treatment. 

LXXII.     THE  FOREARM  AND  HAND 590-603 

Greenstick  fracture  of  the  forearm — Volkmann's 
ischemic  contracture — Subluxation  of  the  head  of  the 
radius:  Symptoms;  Treatment — Madelung's  deform- 
ity— Fracture  of  the  lower  end  of  the  radius — Tu- 
berculosis of  the  wrist:  Symptoms;  Prognosis; 


XIX 


Treatment — Tuberculosis  of  the  phalanges — Con- 
genital deviations  of  the  hand:  Varieties;  Eti- 
ology; Treatment — Injuries  of  the  hand  in  child- 
hood— Malformation  of  the  fingers;  Polydactyly; 
Syndactyly;  Ectrodactyly ;  Clubbed  thumb. 


SECTION  XIV 
THE  LOWER  EXTREMITY 

LXXIII.     CONGENITAL  DISLOCATION  OF  THE  HIP  . 

Etiology    and    pathology — Symptoms — Diagnosis- 
Prognosis — Treatment. 


604-611 


LXXIV.     COXA  VARA  AND  COXA  VALGA 612-615 

Coxa  vara :  Etiology  and  pathology ;  Symptoms ; 
Diagnosis;  Prognosis;  Treatment — Coxa  Valga : 
Etiology;  Symptoms;  Diagnosis;  Treatment. 

LXXV.     HIP  JOINT  DISEASE 615-628 

Pathology  —  Symptoms  --  Diagnosis  —  Differen- 
tial Diagnosis — Prognosis — Treatment. 

LXXVI.     FRACTURE  OP  THE  FEMUR 628-632 

Fracture  of  the  neck  of  the  femur:  Diagnosis; 
Treatment;  Fracture  of  the  Shaft  of  the  femur: 
Pathology;  Diagnosis;  Treatment. 

LXXVII.     AFFECTIONS  OF  THE  KNEE 632-646 

Congenital  absence  of  the  knee — Congenital  dislo- 
cation of  the  patella — Injury  of  the  tubercle  of  the 
tibia — Genu  valgum:  Age  of  occurrence;  Symp- 
toms; Prognosis;  Treatment — Genu  varum — Eti- 
ology; Symptoms;  Prognosis;  Treatment — Genu  re- 
curvatum — Tuberculosis  of  the  knee:  Pathology; 
Symptoms;  Diagnosis;  Prognosis;  Treatment. 

LXXVIII.     TIBIA  AND  FIBULA 646-650 

Rachitic  curvatures  of  the  leg:  Pathology;  Treat- 
ment— Congenital  absence  of  the  fibula :  Pathology ; 
Diagnosis;  Treatment — Congenital  absence  of  the 
tibia :  Pathology ;  Prognosis ;  Treatment. 


xx  CONTENTS 

CHAPTER  PAGE 

LXXIX.     DEFORMITIES  OF  THE  FOOT 650-669 

Club  foot:  Etiology;  Pathological  anatomy;  Symp- 
toms; Prognosis;  Treatment — Acquired  club  foot — 
Paralytic  club  foot — Talipes  equinus:  Pathology; 
Symptoms ;  Treatment — Pes  cavus — Pathology ; 
Treatment — Talipes  calcaneus — Flat-foot;  Anatom- 
ical considerations;  Varieties;  Symptoms;  Diag- 
nosis; Prognosis;  Treatment. 

LXXX.    AFFECTIONS  OF  THE  ANKLE  AND  TOES      .        .        .     669-674 
Tuberculosis  of  the  ankle:   Pathology;  Symptoms; 
Prognosis;    Treatment — Deformities    of    the    toes: 
Claw  foot;   Hallux   valgus;    Hallux  varus;   Ham- 
mer-toe. 

INDEX 677 


LIST  OF    ILLUSTRATIONS 

FIG.  PAGE 

1.  The  marked  differences  between  the  child  and  the  adult 7 

2.  Comparative   size   of   lower   jaw  in    infant   and   adult,   showing- 

changes  during  development    8 

3.  A  composite  chart  of  the  respirations  of  twenty  infants  of  four 

months  of  age 11 

4.  History  card   13 

5.  Rachitic  type  of  skull 16 

6.  Tlie  teeth  between  six  and  eight  months 17 

7.  The  teeth  two  months  after  the  appearance   of  the   two   lower 

central   incisors    17 

8.  The  teeth  between  twelfth  and  fourteenth  months  18 

9.  The  teeth  between  sixteenth  and  twenty-second  months 18 

10.  The  teeth  between  the  twenty-second  and  twenty-eighth  months . .  19 

11.  Side  posture  characteristically  assumed  in  painful  conditions  of 

chest  and  sometimes  when  one  side  of  abdomen  is  affected ....  22 

12.  Dorsal  posture,  which  is  posture  assumed  by  child  most  often  in 

peritonitis,  perinephritis,   appendicitis    22 

13.  Posture  "on  the  abdomen" 23 

14.  Pain  in  the  lateral  wall  of  the  chest 29 

15.  Pain  in  the  epigastrium   30 

16.  General  abdominal  pain   33 

17.  Diagnostic  significance  of  headache  in  children 41 

18.  Mastoid  abscess  showing  characteristic  swelling  behind  ear  and 

pushing  auricle  forward 43 

19.  Puncturing  the  lobe  of  the  ear  with  a  needle  with  cutting  edge 

to  obtain  specimen  of  blood  without  injury  to  the  corpuscles. .  47 

20.  Transferring  blood  from  lobe  of  ear  to  the  cover  glass 48 

21.  Placing  cover  glass  with  specimen  of  blood  upon  glass  slide 49 

22.  Method  of  spreading  specimen  of  blood  upon  slide  for  dry  smear.  52 

23.  Puncture  of  a  vein  to  secure  blood  for  examination 53 

24.  Throwing  the  jaw  forward  during  anesthesia 60 

25.  Gwathney   anesthesia   apparatus 62 

26.  Convenient  container  for  small  quantities  of  chloroform 63 

27.  Apparatus  and  method  used  in  intubation  anesthesia 65 

28.  First  step  in  infiltration  anesthesia    71 

29.  Second  step  in  infiltration  anesthesia 72 

30.  Relative  cardiac  dullness  and  absolute  cardiac  dullness  in  an  in- 

fant of  one  year  81 

xxi 


xxii  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

31.  Area  of  relative  cardiac  dullness  and  absolute  cardiac  dullness  in 

child  of  six  years 81 

32.  Area  of  relative  cardiac  dullness  and  absolute  cardiac  dullness  in 

child  of  twelve  years 81 

33.  Condom  tied   over  penis  to  collect   specimen   of  urine  for  ex- 

amination      82 

34.  Chapin  urinal 82 

35.  Chapin  urinal  in  position 83 

36.  Mosquito  forceps   85 

37.  Child  properly  attended  after  operation,  body  being  adequately 

protected  and  vomitus  taken  care  of 90 

38.  Child  neglected  after  operation   92 

39.  Apparatus  for  stomach  washing 102 

40.  Lavage  in  older  child   103 

41.  Apparatus  for  rectal  washing  or  rectal  feeding 105 

42.  Side  view  of  rachitic  boy 116 

43.  Rachitic   deformity    117 

44.  Rachitic   deformity    117 

45.  Rachitic  deformity  in  child  of  fifteen  months 119 

46.  Comparative  contours  of  normal  and  rachitic  stomach 120 

47.  Typical  case  of  rickets 122 

48.  Comparative  chest  contours 123 

49.  Typical  bowing  of  the  legs  in  a  rachitic  child 124 

50.  Leg  of  rachitic  child 126 

51.  Cranial  contours :  anteroposterior — circumference — transverse  . . .  127 

52.  Marked  raehitic   deformity    129 

53.  Head  of  syphilitic  infant  showing  characteristic  fissures  at  cor- 

ners of  mouth  and  generally  shriveled  appearance 142 

54.  Head  of  syphilitic  infant,  showing  the  destruction  of  the  hair. .  143 

55.  Congenital  syphilis    144 

56.  Gumma  of  the  leg  in  syphilitic  infant 146 

57.  Gumma  of  the  eyelid 147 

58.  Saber-like  appearance  of  leg  sometimes  observed  in  congenital 

syphilis    148 

59.  Hutchinson's  teeth   149 

60.  Salivary  calculi  remotely  simulating  adenitis  161 

61.  Front  view  of  same  case  as  Figure  60  161 

62.  Location  of  the  principal  lymphatic  glands  of  neck 163 

63.  Location  of  the  principal  lymphatic  glands  of  trunk 164 

64.  Tuberculous  adenitis  168 

65.  Tuberculous  adenitis,   showing  marked   enlargement  which  may 

sometimes  take  place  without  glands  breaking  down 168 

66.  Abscess  pointing  in  front  of  upper  part  of  the  sternomastoid 169 

67.  Abscess  pointing  in  front  of  lower  part  of  sternomastoid 170 

68.  Abscess  pointing  behind  upper  part  of  sternomastoid 171 


LIST    OF    ILLUSTRATIONS  xxiii 

FIG.  PAGE 

69.  Abscess  pointing  in  front  of  sternomastoid 172 

70.  Showing  it  is  unsafe  to  expect  disease  to  be  self-limited 173 

71.  Illustrative  of  the  same  proposition  as  Figure  70 173 

72.  Suppurative  osteomyelitis  of  the  tibia 177 

73.  Diagram  to   show  removal  of  portion   of  tibia  and  relation   of 

infolded  periosteum  181 

74.  Von  Pirquet  test  for  tuberculosis   189 

75.  Morro  test  for  tuberculosis   190 

76.  Tuberculous  infection  of  bones  of  face 196 

77.  Sites  for  injection  of  sera  or  vaccines  in  children 236 

78.  Proper  position  for  treatment  of  burns  involving  neck 237 

79.  Incorrect  position  in  burns  of  the  arm  or  axilla  238 

80.  Correct  position  for  child  with  extensive  burns  of  the  arm  or  axilla  239 

81.  An  incorrect  and  particularly  bad  position  for  burns  of  palm  of 

-hand    240 

82.  Incorrect  position  for  hand  in  burns  of  even  moderate  degree.  . .  .  241 

83.  Correct  position  in  burns  of  the  palm  of  the  hand 242 

84.  An  incorrect   posture   for  the  leg  when  it  is  site  of  extensive 

burns    243 

85.  Correct  position  of  the  leg  in  extensive  burns 243 

86.  The  results  of  incorrect  position  and  delayed  skin  grafting  in  ex- 

tensive burn  of  the  neck 

87.  Side  view  of  same  case  as  Figure  86 

88.  Greenstick  fracture  of  the"  forearm 

89.  Double  rectangular  splint  and  position  of  arms  when  applied  in 

fracture  of  the  humerus   249 

90.  The  inverted  T-shaped  splint  and  position  of  arms  when  applied 

in  fracture  of  clavicle   250 

91.  Splints  in  position  in  fracture  of  femur 251 

92.  Dressing  completed  in  fracture  of  femur 251 

93.  Line  of  upper  epiphysis  of  humerus  and  how  end  of  diaphysis 

fits  into  it 253 

94.  Traumatic  separation  at  upper  epiphysis  of  humerus 254 

95.  Arrest  of  development  of  right  arm  due  to  early  traumatic  sepa- 

ration of  the  epiphyseal  cartilage   255 

96.  Showing  epiphysis  of  femur   255 

97.  Separation  lower  epiphysis  of  the  femur 256 

98.  Lower  epiphysis  of  humerus  centers  of  ossification  of  capitellum 

and  internal  condyle    257 

99.  The  normal  epiphyseal  line  at  upper  end  of  tibia  and  fibula 257 

100.  Testing  the  knee  reflexes   265 

101.  Correct  posture  for  performance  of  lumbar  puncture 271 

102.  Locating  the  right  point  of  entrance  in  lumbar  puncture 272 

103.  Needle  in  position  and  fluid  being  collected  in  sterile  tube 273 

104.  Upright  position  for  lumbar  puncture 274 


XXIV 

no.  PAGE 

105.  Upright  position  in  lumbar  puncture — needle  in  place  and  fluid 

flowing    275 

106.  Age  incidence  in  poliomyelitis  as  observed  in  1909  epidemic  in 

Brooklyn,  N.  Y.,  by  authors  299 

107.  Seasonal  incidence  of  poliomyelitis  as  observed  by  authors  in  1909  300 

108.  Atrophy  of  the  musculature  of  leg  following  poliomyelitis 304 

109.  Hernia  of  abdominal  wall  due  to  paralysis  of  abdominal  muscles 

in  poliomyelitis 305 

110.  Flail-like  limb,  the  result  of  paralysis  and  atrophy  of  poliomye- 

litis    307 

111.  Sarcoma  of  the  kidneys 332 

112.  Sarcoma  of  the  kidnejrs 333 

113.  Sarcoma  of  kidneys  removed  from  child  of  two  years 335 

114.  Angioma 342 

115.  Anterior  meningocele  springing  from  root  of  nose 354 

116.  Large  occipital  encephalocele   354 

117.  Microcephalus  with  encephalocele   356 

118.  Hydrocephalic  child 357 

119.  Bat  ears 362 

120.  Macroglassia    368 

121.  A. — Unilateral  hare-lip.    B. — Bilateral  hare-lip 371 

122.  Steps  in  operation  for  simple  notch  in  border  of  the  lip 373 

123.  Steps  in  operation  for  complete  fissure  of  the  lip 373 

124.  V-shaped  interval  filled  by  the  intermaxillary  bone 376 

125.  Complete  cleft  involving  hard  and  soft  palate 376 

126.  Mouth-gag  with  sharp  teeth  that  bite  into  the  gum 378 

127.  Convenient  forms  of  small-bladed  knives 378 

128.  Lane  needle,  holder  and  needles 379 

129.  Lines  of  incision  for  repair  of  a  median  cleft  in  infancy 380 

130.  Method  of  fixation  of  the  reflected  flap  beneath  the  elevated  flap 

by  a  double  row  of  sutures  381 

131.  Flaps  sutured  in  position  for  repair  of  median  cleft 381 

132.  Incomplete  cleft  palate  without  hare-lip  operated  at  fourth  week.  382 

133.  Hare-lip  and  cleft  palate  operated  at  the  third  week  382 

134.  The   cricothyroid   membrane   through    which    rapid   tracheotomy 

may  be  performed  388 

135.  Position  of  the  child  for  intubation 390 

136.  Instruments  used  in  intubation    391 

137.  A. — Method  of  drawing  the  epiglottis  forward.     B. — Introducing 

tube  alongside  of  finger.     C. — Pushing  tube  into  position  with 

index  finger 392 

138.  Outer  tube  of  tracheal  cannula.  B. — Inner  tube  of  tracheal  cannula  394 

139.  Improvised  tracheal  cannula  made  from  rubber  tubing 395 

140.  Torticollis    397 

141.  Lines  of  incision  for  plastic  operation  on  the  sternomastoid  muscle  398 


LIST    OF    ILLUSTRATIONS  xxv 

yiQ-  PAGE 

142.  Bilateral  tuberculous  glands  of  the  neck 400 

143.  Line  of  incision  for  the  radical  removal  of  tuberculous  glands  of 

the  neck 403 

144.  Location  of  the  orifices  of  persistent  bronchial  fistula? 404 

145.  Congenital  lymphatic  cyst  of  the  neck   400 

146.  The  esophageal  tube,  showing  the  three  points  of  construction. . .  411 

147.  Spina   bifida    417 

148.  Ulcerating  spina  bifida  419 

149.  Spina  bifida  occulta    420 

150.  Sacral  tumor  before  operation   422 

151.  Showing  result  after  removal  of  sacral  tumor  423 

152.  Drainage  tubes  in  wound  after  resection  of  rib 428 

153.  The  normal  contour  of  the  spinal  column  430 

154.  Rachitic   kyphosis    432 

155.  The"faulty  posture  resulting  in  the  "pot-belly"  of  abdominal  ptosis  433 

156.  Faulty  and  correct   posture    434 

157.  Bending  exercises  with  hands  behind  the  back  for  the  correction 

of  round  shoulders    435 

158.  Breathing  exercise  for  the  correction  of  round  shoulders 435 

159.  Faulty   sitting   position    436 

160.  Scoliosis   437 

161.  Distortion  of  the  ribs  in  lateral  curvature 440 

162.  Method  of  applying  adhesive  strip  to  back  on  which  the  line  of 

spinous  processes  is  traced  for  future  reference 442 

163.  Kyphosis  of  Pott's  disease 448 

164.  Characteristic  attitude  of  patient  in  picking  up  an  object  from 

the  ground 451 

165.  Method  of  demonstrating  normal  flexibility  of  the  spine 453 

166.  Method  of  demonstrating  rigidity  of  the  spine 453 

167.  The  Whitman-Bradford  frame   457 

168.  The  Taylor  brace  for  supporting  the  spine 458 

169.  Support  for  the  head  attached  to  the  upper  part  of  the  Taylor 

brace     459 

170.  The  "hammock  frame"  of  Bradford  and  Lovett 460 

171.  Method  of  applying  plaster  jacket  in  the  Bradford-Lovett  frame.  460 

172.  The  Calot  jacket  with  opening  over  kyphos  for  the  intersection  of 

cotton-pads  to  diminish  deformity 461 

173.  Lateral  view  of  the  transposed  spinous  processes 463 

174.  Method  of  applying  adhesive  strips  for  maintaining  reduction  in 

infantile  umbilical  hernia 473 

175.  Migration  of  testicle  and  tube-like  process  of  peritoneum  pro- 

jected into  the  scrotum   475 

176.  Relation  of  testicle  to  vaginal  process  of  peritoneum  just  before 

birth 476 

177.  The  final  and  normal  disposition  of  the  vaginal  process 476 


xxvi  LIST    OF    ILLUSTRATIONS 

no.  PAGE 

178.  Congenital  inguinal  hernia    477 

179.  Method  of  shaking  the  hernial  contents  back  into  the  abdominal 

cavity    480 

180.  Cross-body  trees  applied  to  left  inguinal  hernia   483 

181.  Showing  method  of  taking  diagi-am  with  lead  tape 484 

182.  Diagram  of  two  persons  whose  measurements  are  identical 485 

183.  Operative  technique  for  the  simple  reducible  hernias  of  childhood .  488 

184.  Exstrophy  of  the  bladder  and  bilateral  undescended  testicle 490 

185.  Diagram  of  stomach  showing  that  its  two-fold  function  is  plainly 

marked  in  its  structure 493 

186.  The  vermiform  appendix    500 

187.  Infantile   cecum    500 

188.  Rectal-bimanual  examination 504 

189.  Operative  technique  for  appendectomy   509 

190.  Intussusception  in  vertical  section   512 

191.  Congenital  idiopathic  dilatation  of  the  colon   510 

192.  Absence  of  anus,  rectum  terminating  in  blind  pouch 518 

193.  Normal  anus  with  anorectal  septum   518 

194.  Rectum  terminating  in  the  vagina 519 

195.  Protrusion  of  the  anal  mucosa  through  the  anal  orifice 521 

196.  Prolapse  of  the  rectum  52:2 

197.  Sarcoma  of  the  kidney 52S 

198.  The  prepuce  held  taut  and  slit  made  along  the  dorsum  of  the 

prepuce    537 

199.  The  excess  prepuce  removed,  leaving  small  collar  of  skin  and 

mucosa  at  base  of  corona   537 

200.  The  skin  and  mucosa  sutured  and  the  ends  of  catgut  left  long  to 

hold  dressing  in  place 537 

201.  Gauze  dressing  tied  in  place 538 

202.  Tapping  a  hydrocele 541 

203.  Bilateral-inguinal  nndescended  testicle   542 

204.  Incision  through  skin,  superficial  fascia,  aponeurosis  of  the  ex- 

ternal oblique,  and  the  peritoneal  pouch  opened  545 

205.  Upper  end  of  vaginal  process  ligated 54(5 

206.  Cord  lengthened,  testicle  freed  and  ready  for  replacement 54(5 

207.  Making  pocket  in  the  scrotum  for  reception  of  testicle ")47 

208.  Duplay's  operation  for  epispadias    551 

209.  Hypospadias  of  the  glands 552 

210.  Penile  hypospadias   553 

211.  Penoscrotal   hypospadias    553 

212.  Beck's  operation 556 

213.  Rochet's   operation    557 

214.  Bucknall's  operation  for  penoscrotal  hypospadias  558 

215.  Congenital  elevation  of  the  scapula 563 

216.  Ankylosis  of  the  shoulder  joint 565 


LIST    OF   ILLUSTBATIONS  xxvii 

««•  PAGE 

217.  Radiograph  of  normal  elbow  at  ten  years 570 

218.  Radiograph  of  normal  elbow  at  two  years 571 

219.  The  four  centers  of  ossification  forming  the  lower  epiphysis  of 

the  humerus    571 

220.  Relation  of  the  three  bony  points  of  the  elbow   574 

221.  The  "carrying  angle"  which  the  supinated  forearm  forms  with 

the  arm    ; 574 

222.  Surface  and  profile  radiograph  of  a  supracondylar  fracture 576 

223.  Supracondylar  fracture    579 

224.  Fracture  of  the  external  condyie    580 

225.  Fracture  of  the  internal  epiconclyle 581 

226.  Internal  angular  splint    585 

227.  Gunstock  deformity  caused  by  obliteration  of  the  carrying  angle.  585 

228.  Application  of  the  internal   angular  splint  for  fracture  of  the 

elbow   587 

229.  First  position  arm  is  held  in  position  of  forced  flexion  by  adhe- 

sive strap.     Second  position  dressing  is  completed  by  plaster 

bandage  enswathing  arm  and  chest    588 

230.  Greenstick  fracture  of  the  bones  of  the  forearm 591 

231.  Fracture  of  the  forearm  immobilized  in  position  of  supination.  .  591 

232.  Madelung's    deformity    593 

233.  Spina  ventosa  596 

234.  Clubbed  hand  with  malformation  of  the  bones  of  the  forearm. .  597 

235.  Syndactyly— Webbed    fingers    601 

236.  Didot's  operation  for  webbed  fingers 601 

237.  Agnew's  operation  for  webbed  fingers 602 

238.  Diagram  showing  displaced  femoral  head  on  the  dorsum  ilii 605 

239.  Bilateral  congenital  dislocation  of  the  hip  in  a  boy  of  fifteen ....  607 

240.  Plaster  fixation  after  reduction  of  a  congenitally  dislocated  hip . .  610 

241.  Coxa  vara   613 

242.  Obliteration  of  the  gluteal  fold  in  disease  of  the  right  hip 618 

243.  The  results  of  malpositions  and  their  effect  on  the  pelvis 619 

244.  Diagram  demonstrating  the  effects  of  malpositions  of  the  limbs  on 

the  pelvis 620 

245.  Patient  on  his  back,  the  knee  of  affected  side  flexed 620 

246.  Diseased  limb  extended  back  arched   621 

247.  Diseased  hip  flexed  until  lordosis  of  spine  is  obliterated,  showing 

amount  of  fixed  flexion  deformity   623 

248.  Extension  applied  on  wheeled  litter 626 

249.  Taylor  hip-splint   627 

250.  A. — Fracture  of  neck  of  femur.    B. — Restoration  of  notarial  angle 

by  forcible  abduction 629 

251.  Long  spica  as  applied  for  treatment  of  fracture  of  neck  of  femur  630 

252.  Vertical  suspension  in  fracture  of  shaft  of  femur 631 

253.  Genu  valgum,  or  "knock-knee"   634 


xxviii  LIST    OF    ILLUSTRATIONS 

FIQ.  PAGE 

254.  "Knock-knee"  brace  of  Bradford  and  Lovett  637 

255.  MacEwen's  supracondyloid   osteotomy 638 

256.  Bilateral  genu  varum   640 

257.  Bow-leg  brace  of  Bradford  and  Lovett 641 

258.  Rachitic  curvatures  of  the  bones  of  the  leg 647 

259.  Congenital  absence  of  the  tibia 649 

260.  Club-foot   651 

261.  Congenital  club-foot 652 

262.  Relation  of  the  tendons  in  front  of  the  ankle 656 

263.  Relations  of  the  structures  behind  internal  malleolus 657 

264.  Taylor's  club-foot  retention  shoe  applied 658 

265.  Varieties  of  deformities  of  the  foot  661 

266.  Pes  cavus 662 

267.  Flat-foot 664 

268.  Print  of  soles  of  a  normal  foot  and  flat-foot 666 

269.  Supernumerary  toe  671 

270.  Hallux  valgus  672 

271.  Hammer  toes    674 


PART  I 
GENERAL 


SECTION  I 
GENERAL  CONSIDERATIONS 

CHAPTER  I 

QUALIFICATIONS   OF   THE   PEDIATRIC   SUEGEON 

The  first  requirement  of  the  surgeon  who  hopes  to  deal  effectively 
with  the  surgicaj  affections  of  childhood  is  a  broad  clinical  experience 
with  surgical  conditions  and  a  perfection  of  operative  technique 
which  has  been  acquired  through  actual  contact  with  many  cases. 
Such  clinical  experience  will  teach  him  that  an  operative  procedure 
in  the  young  requires  more  preliminary  planning,  more  rapid  operat- 
ing, and  infinitely  more  gentle  manipulation  of  tissues  than  a  similar 
procedure  in  older  persons.  There  are  to-day  very  many  conditions 
which  are  forcing  the  public  and  the  medical  profession  to  recognize 
the  fact  that  the  care  of  children  is  a  more  or  less  complex  problem. 

We  must  recognize  the  fact  that  there  are  surgical  conditions 
which  are  unknown  to  childhood ;  that  there  are  those  also  that  are 
peculiar  to  that  period  of  life,  and  that  a  particular  disease  is  varied 
in  its  manifestations  as  it  is  observed  in  the  different  periods  of 
childhood. 

To  that  knowledge  which  he  already  possesses  of  the  details  of 
scientific  medicine  and  surgery,  the  pediatric  surgeon  must  also 
bring  a  knowledge  of  and  love  for  children.  And  it  is  not  sufficient 
to  know  how  disease  or  injury  affects  children;  he  must  also  know 
how  children  react  to  disease. 

The  ability  to  correctly  diagnose  and  to  treat  the  surgical  condi- 
tions of  childhood  can  be  met  in  two  ways.  The  surgeon  may  per- 
fect himself  as  far  as  possible  in  the  diseases  of  children,  and,  if 
this  knowledge  is  augmented  by  large  powers  of  close  observation 
and  a  discerning  and  discriminating  judgment,  he  is  well  equipped 
for  his  task.  However,  if,  lacking  the  time  or  opportunity  to  be- 

3 


4  THE    EXPRESSION    OE    DISEASE 

come  unusually  proficient  in  the  medical  as  well  as  the  surgical 
diseases  of  childhood,  he  may  make  use  of  the  skill  of  the  trained 
pediatrician.  In  fact,  if  the  operative  technique  and  courage  of 
the  skilled  surgeon  were  more  often  coupled  with  the  knowledge  and 
judgment  of  the  pediatrist,  the  surgical  results  to  the  child  would 
be  much  better.  And  no  small  part  of  the  surgeon's  success  with 
children  will  be  due  to  his  tact,  his  sympathy,  his  gentle  firmness,  and 
ability  to  inspire  confidence  in  the  particular  child  under  examina- 
tion. 

The  statement  that  the  pediatric  surgeon  must  be  more  than 
a  skilled  operator  is  not  Utopian;  there  are  very  definite  reasons 
for  the  statement. 

Disease  in  the  infant  or  young  child  does  not  express  itself  as 
in  the  adult,  therefore  the  pediatric  surgeon  must  understand  much 
of  this  difference  and  be  able  to  interpret  it  correctly.  A  brief 
resume  of  some  of  these  differences  must  be  instructive. 


CHAPTER  II 

THE  EXPEESSION  OF  DISEASE  IN  THE  YOUNG  CHILD 

The  clinical  manifestations  of  disease  in  infancy  and  in  ma- 
turity are  vastly  different ;  it  is  this  difference  that  makes  the  appre- 
ciation of  disease  in  the  infant  difficult.  The  familiar  things  which 
are  used  as  the  foundation  for  building  up  the  superstructure  of 
diagnosis  in  the  adult  are  in  infants  entirely  absent,  or  are  so  totally 
different  that  they  are  misleading.  In  approaching  the  infant  the 
inexperienced  are  at  once  confronted  with  a  sense  of  loneliness  sim- 
ilar to  that  which  overcomes  the  stranger  in  a  strange  land ;  a  land  in 
which  there  are  few  familiar  scenes  and  none  to  guide. 

While  there  are  many  diseases  which  are  peculiar  to  the 
period  of  life  known  as  infancy,  it  is  the  peculiarity  of  the  patient 
as  much  as  the  disease  which  must  interest  us,  for  it  is  this  that 
leads  to  the  varied  expression  of  disease.  Of  prime  importance  in 
the  study  of  any  disease  is  the  accuracy  with  which  a  diagnosis  may 
be  made.  In  infancy  this  entails  that  we  must  be  acquainted  witb 


THE    EXPRESSION    OF    DISEASE  5 

facts  about  the  infant  which  have  no  direct  bearing  upon  the  disease 
or  injury  present,  but  which  must  often  modify  or  entirely  change 
our  usual  interpretation  of  symptoms.  For  instance,  we  are  always 
conscious  of  the  insignificant  influence  of  the  mind  upon  disease  in 
infancy,  for  the  diagnostic  possibility  is  appreciably  limited  by  the 
fact  that  psychic  neurotic  influences  are  almost  excluded. 

The  various  tissues  may  also  be  incapable  of  exhibiting  phe- 
nomena which  are  the  result  of  certain  etiological  factors,  or  in  their 
immaturity  they  may  respond  more  easily  and  certainly  to  other 
factors.  And,  again,  even  in  the  presence  of  a  definite  symptoma- 
tology, the  reasoning  and  deduction  as  to  its  cause  must  be  entirely 
distinct  from  the  same  processes  as  they  apply  in  adult  life.  For  in- 
stance, the  very"young  infant  is  comparatively  free  from  convulsive 
seizures,  because,  during  the  first  three  months  of  life,  the  acute  sys- 
temic bacterial  toxemias,  which  are  potent  factors  in  the  etiology  of 
convulsions,  are  infrequent.  Then,  again,  stimulation  of  the  cortical 
motor  centers  and  of  the  convulsive  centers  at  the  base  of  the  brain 
does  not  excite  convulsive  movement  easily,  because  the  nerve  force 
discharged  from  these  centers  is  hindered  in  its  dissemination  by  the 
under-development  of  the  myelin  sheaths  of  the  fibers  of  the  pyram- 
idal tracts.  These  sheaths  are  gradually  developed  so  that  about 
the  third  or  fourth  month  of  life  the  pyramidal  tracts  have  their 
functions  sufficiently  developed  to  bring  the  spinal  cells  and  the 
cerebral  convulsive  centers  into  close  touch. 

But  after  the  third  month  and  until  the  end  of  the  second 
year  all  of  the  nerve  centers  are  most  irritable,  so  that  convulsive 
seizures  are  common.  The  clinical  import  of  this  is  that  convul- 
sions in  the  very  young  infant  are  of  serious  import  and  that 
not  infrequently  after  their  subsidence  there  is  some  weakness  of 
the  affected  musculature.  That  convulsions  occurring  at  the  onset  of 
some  disease  in  an  infant  between  the  ages  of  three  months  and 
two  years  are  of  but  little  import  and  may  be  due  to  the  most 
trivial  cause,  while  in  adult  life  any  such  event  at  any  time 
would  be  sufficient  cause  for  great  alarm. 

The  necessity  of  recognizing  these  differences  must  be  appar- 
ent, because  it  is  by  a  correct  analysis  of  them  that  we  are  enabled 


6  THE    EXPRESSION    OF    DISEASE 

to  determine  the  import  of  symptoms.  Not  infrequently  apparently 
mild  symptoms  are  interpreted  as  indicative  of  mild  disease,  while 
seemingly  more  grave  ones  arouse  unnecessary  alarm  and  foster  the 
drawing  of  wrong  conclusions. 

Take,  for  example,  the  symptomatology  of  an  acute  illness  in 
the  infant  or  the  results  of  an  injury;  we  find  that  there  is  not 
the  limitation  of  symptoms  referable  to  the  particular  organ  or  re- 
gion which  is  primarily  involved  as  in  adult  life,  but  the  infant 
becomes  the  subject  of  more  general  or  constitutional  symptoms. 
Thus  the  expression  of  the  disease  or  injury  is  more  constitutional 
than  focal  and  the  younger  the  child  the  more  striking  the  con- 
trast. 

This  is  largely  due  to  the  fact  that  there  is  an  inability  in  in- 
fancy to  focalization  of  nervous  function  because  immaturity  leads 
to  an  interference  with  the  complete  mechanism  of  inhibitory  con- 
trol. 

Then  again,  the  reflexes  are  not  restrained,  but  become  general- 
ized, leading  to  the  appreciation  of  constitutional  symptoms.  And 
so  we  observe  that  nervous  phenomena  which  would  be  of  grave 
import  in  later  life  lose  much  of  their  gravity  because  they  occur 
in  the  immature. 

For  instance,  the  onset  of  most  of  the  acute  diseases  of  infancy 
gives  rise  to  one  or  more  convulsions,  an  event  which  is  practically 
unheard  of  in  adult  life.  Such  convulsions  are  almost  always  mild 
in  their  effect  upon  the  infant  and  cause  little  or  no  alarm  to  the  one 
who  is  experienced  enough  to  determine  their  significance  and  give 
them  their  proper  value. 

And  again,  the  digestive  system  bears  considerable  of  the  brunt 
of  the  invasion  of  any  disease  in  infancy,  so  that  it  is  our  common 
experience  to  observe  the  symptoms  of  vomiting,  diarrhea,  or  consti- 
pation at  the  onset  of  most  of  the  diseases  of  infancy.  Even  making 
allowance  for  the  ease  with  which  disease  of  the  digestive  apparatus 
is  produced  in  infants,  the  fact  remains  that  a  considerable  propor- 
tion of  disturbance  which  is  laid  to  digestive  disease  is  due  only  to 
the  onset  of  some  acute  infection. 

The  inarticulate  expression   of  disease   in  infants  has   several 


THE    EXPBESSION    OF    DISEASE  7 

qualities  which  adults  do  not  possess.  And  first  among  these  is 
absolute  honesty  of  such  expressions. 

An  infant's  philosophy  (if  we  may  call  it  such)  is  contained  in 
this  statement:  "All  that  is  painful  is  evil;  all  that  is  pleasurable 
is  good." 

To  the  infant  the  mere  act  of  living  in  contentment  is  sufficient 
and  this  sufficiency  takes  no  recognition  whatever  of  the  future,  but 
is  limited  to  the  comfort  of  the  moment.  Neither  is  there  any  liv- 


FIG.   1. — THE  MARKED  DIFFERENCES  BETWEEN  THE  CHILD  AND  THE  ADULT. 
At  birth;  the  head  repre-       At    six    years;    the    head       In    adult    life;    the    head 


sents    one-fourth   of    the 
whole  length  of  the  body. 


six    years; 
represents    one-sixth    of 
the  body  length. 


represents  one-eighth  of 
the    body   length. 


ing  in  the  past,  and  this  is  aptly  illustrated  by  the  experiences  of  an 
infant  in  pain  either  from  disease  or  injury.  With  the  quick  sub- 
sidence of  the  pain  there  is  an  immediate  return  to  the  usual  play- 
fulness and  no  recollection  of  the  past. 

Health  and  Disease  are  terms  that  have  for  the  infant  no  con- 
tent. 

This  fact  of  living  for  the  moment  is  one  of  the  chief  factors  in 
the  discomfort  attendant  upon  enforced  restraint.  The  infant  dis- 


8  THE    EXPRESSION    OF    DISEASE 

likes  illness  and  by  nature  his  rebellion  against  the  restraint  which 
an  illness  enforces  is  absolutely  honest. 

This  should  lead  one  to  appreciate  the  fact  that  if  an  infant 
shows  any  tendency  to  lose  interest,  to  lag  in  its  play,  to  become 
fretful,  or  act  as  if  in  discomfort,  the  cause  should  be  sought  in 
the  bodily  health. 

Therefore,  muscular  activity,  which  is  an  important  factor  in 
the  growth  and  development  of  infants,  is  responsible  for  some  of 
the  peculiarities  which  are  noted  in  illness. 

In  fact,  the  disinclination  to  continue  the  usual  muscular  activ- 
ity should  be  interpreted  as  an  early  sign  of  ill  health,  and  this  is 
often  expressed  by  the  infant  in  the  desire  to  be  left  undisturbed. 

The  common  accompaniment  of  diminished  muscular  activity 
is  a  diminution  of  mental  activity,  and  the  infant  loses  interest 
in  its  surroundings  because  the  exertion  demanded  by  the  attentive 
attitude  is  unpleasant. 

And  so  when  illness  or  injury  has  marked  one  of  these  little 
ones  as  its  victim,  this  same  antagonism  to  illness,  this  rebellion 


FIG.  2. — COMPARATIVE  SIZE  OF  LOWER  JAW  IN  INFANT  AND  ADULT, 
SHOWING  ALSO  THE  VERY  MARKED  CHANGES  WHICH  TAKE 
PLACE  DURING  DEVELOPMENT. 

against  the  consequent  restraint,  keeps  the  infant  from  the  magnifi- 
cation or  multiplication  of  its  symptoms. 

Further  than  this  the  infant  is  entirely  uninfluenced  by  the 
habit  of  morbid  introspection  and  is  therefore  incapable  of  exaggerat- 
ing its  ills  for  the  sake  of  attracting  attention  to  itself.  Whatever 
exaggeration  takes  place  is  due  to  the  parent  who  gives  the  history, 
and,  through  innocence  or  design,  distorts  the  facts ;  or  to  the  surgeon 
who  allows  the  given  history  to  influence  his  judgment  more  effect- 
ively than  what  he  finds  by  observation  and  examination. 


THE    EXPRESSION    OF    DISEASE  9 

We  have  more  than  once  heard  it  stated  that  even  infants  would 
exaggerate  their  ailments,  and  that  the  quality  of  introspection  in 
them  was  not  entirely  wanting.  But  this  has  always  been  based 
upon  the  demands  which  some  children  make  upon  their  attendants 
during  an  illness.  Much  of  this  is  the  result  of  habit  which  has 
been  formed  during  periods  of  health  and  is  not  a  part  of  the  ill- 
ness. 

There  is  no  doubt  that  children  need  and  demand  more  sympathy 
than  any  other  class  of  patients,  but  the  demand  for  it  rarely  exceeds 
the  need.  The  infant  crying  in  his  apprehension  may  be  labeled 
by  the  inexperienced  as  a  disturber  of  the  peace,  but  not  so  to  the 
mother  who  understands  the  meaning  of  the  cry  and  who  is  moved  by 
its  eloquence.  "To  the  infant  her  arms  are  as  a  narcotic  and  when 
the  mental  need  is  fully  supplied  there  is  no  further  demand. 
Therefore  the  mental  attitude  of  the  infant,  at  least,  may  be  taken 
as  a  safe  guide  and  index  to  his  bodily  state.  Of  course,  in  the  case 
of  older  children  who  have  been  indulged  and  spoiled,  some  considera- 
tion must  be  given  by  the  surgeon  to  these  factors. 

From  these  general  facts,  which  are  not  always  appreciated  and 
may  even  be  unknown,  we  can  readily  see  that  the  more  definite  ex- 
pression of  disease  in  children  is  often  misinterpreted  or  unrecog- 
nized. 


SECTION  II 

EXAMINATION 

CHAPTER  III 

THE  EXAMINATION 

General  Considerations. — The  examination  of  infants  and  chil- 
dren offers  many  difficulties  and  peculiarities  which  do  not  obtain 
in  adult  life.  Naturally  the  greatest  contrast  to  adult  life  is  ex- 
hibited by  the  infant  (the  child  under  the  age  of  two  years).  After 
the  end  of  the  second  year  this  contrast  becomes  progressively  less, 
so  that  with  the  arrival  at  the  age  of  puberty  and  the  completion  of 
the  physiological  upheaval  which  takes  place  at  that  period,  the 
child  becomes  the  adult.  During  all  of  this  period  from  birth  to 
puberty  there  are  very  marked  differences  in  the  surgical  conditions 
which  may  occur  and  these  refer  particularly  to  the  etiology,  the 
pathology,  the  symptomatology,  diagnosis,  and  treatment. 

The  commonly  accepted  idea  that  as  soon  as  the  child  is  able  to 
express  its  wants  and  its  feelings  with  a  considerable  degree  of  in- 
telligence it  becomes  an  adult  in  miniature  is  wrong.  The  child 
bears  to  the  adult  a  relation  of  potentiality;  nothing  more.  A  com- 
plete description- of  all  the  changes  which  take  place  and  mark  the 
child  as  being  distinctively  different  from  the  adult  would  include 
each  element  of  mental  and  physical  growth  and  even  the  most 
general  recognition  of  these  differences  emphasizes  the  error  of 
applying  exactly  the  same  methods  of  examination  as  in  the  adult. 
The  proper  surgical  examination  of  the  child  requires  a  previous  in- 
timate knowledge  of  the  normal  child  at  the  various  periods  of  its 
growth  and  development.  And  without  an  intimate  acquaintance 
with  the  morbid  tendencies  which  are  peculiar  to  each  of  these 
periods,  and  a  clear  understanding  of  the  fact  that  from  slightly 
active  causes  the  child,  with  its  unstable  equilibrium,  will  exhibit 

10 


WHAT    IS    THE    AGE?  11 

the  most  varied  and  irregular  disturbances,  one  is  certain  to  bo  led 
into  serious  error. 

It  is  essential  that  the  surgeon  have  a  clear  understanding  of  the 
various  congenital  conditions  and  affections  and  also  know  intimately 
the  usual  surgical  diseases  and  conditions  which  occur  at  the  several 
periods  of  childhood. 

The  tendency  among  surgeons  has  been  to  somewhat  disregard 
the  general  condition  and  nutrition  of  the  child  and  to  divert  all 
of  the  attention  to  a  consideration  of  the  disease  or  injury  present 
and  to  look  upon  that  simply  as  a  mechanical  proposition  or  a  field 
for  operative  procedure.  Such  an  attitude  does  not  give  to  the  child 
the  best  chance,  for,  in  considering  the  problems  connected  with  a 
possible  surgical  intervention,  the  surgeon  gains  much  and  gives 
much,  if  he  takes  cognizance  of  the  child's  organism  as  a  whole. 


RAPID      PAUSE      IRREGULAR       PAUSE     IRREGULAR 


PAUSE   RAPID    PAUSE   IRREGULAR    PAUSE     RAPID 


FIG.  3. — A  COMPOSITE  CHART  OF  THE  RESPIRATIONS  OF  20  INFANTS  OF  FOUR  MONTHS 

OF  AGE. 
This  represents  the  respirations  for  a  full  minute  while  the  infants  were  at  rest. 

This  broader  view  of  his  sphere  of  work  will  aid  in  the  discovery 
and  relief  of  underlying  conditions  or  in  the  avoidance  of  unpleasant 
(and  at  times  fatal)  complications  during  convalescence  from  an  op- 
erative procedure. 

What  Is  the  Age? — This  is  a  question  the  answer  to  which  will 
largely  influence  the  diagnosis.  There  are  many  diseases  which  are 
subject  to  the  influence  of  factors  which  are  active  at  one  period  of 
life  but  which  are  inactive  at  other  times.  Diseases  of  the  new-born 
give  immediate  evidence  of  their  existence  or  at  most  the  event  is  de- 
layed for  but  a  few  days.  This  is  particularly  true  of  the  injuries 
which  may  occur  as  the  result  of  labor,  and  for  illustration  we  need 
only  mention  caput  succedaneum,  cephalhematoma,  hematoma  of  the 


1-2  THE  EXAMINATION 

sternocleidomastoid,  visceral  hemorrhages,  obstetric  palsies,  tetanus 
neonatorum,  atelectasis,  ophthalmia  neonatorum,  etc.  Congenital 
surgical  conditions  are  at  once  evident.  We  might  take  for  illus- 
tration the  two  conditions  of  hemophilia  and  hemorrhagic  disease  of 
the  newly  born.  These  two  are  commonly  confused,  though  they  are 
totally  dissimilar.  For  instance  in  hemophilia  the  bleeding  takes 
place  as  the  result  of  some  trivial  injury  or  accident,  and  may  begin 
or  continue  at  any  time  during  life.  Usually  the  symptoms  do  not 
appear  until  after  the  first  year  of  life,  and  predominate  in  the  case 
of  males  as  high  as  13  to  1.  But  in  hemorrhagic  disease  of  the 
newly  born  the  symptoms  almost  invariably  are  present  before  the 
twelfth  day  of  life,  and  are  rapidly  fatal  or  may  continue  for  a  few 
weeks,  but  whatever  the  course  the  occurrence  of  hemorrhage  is 
self-limited.  Hemorrhages  occur  spontaneously,  and  entirely  irre- 
spective of  injury.  Therefore,  we  can  readily  see  that  the  question 
of  age  sometimes  becomes  a  very  important  factor  in  diagnosis. 

General  History  Taking. — Naturally  there  arise  conditions  of  in- 
jury or  disease  in  children  which  at  once  place  the  matter  as  an 
emergency,  and  the  surgeon  in  such  instances  may  feel  impelled  by 
the  circumstances  to  proceed  at  once  to  apply  the  measures  which 
experience  shows  offer  the  greatest  relief.  These  are  the  few  in- 
stances in  which  full  history  taking  may  be  delayed  until  an  oppor- 
tune time,  but  even  though  delayed  it  should  not  be  neglected.  It  is 
not  an  uncommon  experience  to  act  in  an  emergency  so  as  to  satis- 
factorily meet  the  demands  of  the  time,  and  while  doing  so  to  form 
an  opinion  quickly  as  to  the  conditions  present,  only  later  to  have 
these  conclusions  completely  upset  by  the  history  as  revealed  later. 

A  careful  record  should  be  made  sooner  or  later  in  every  instance 
and  the  details  of  such  a  record  do  not  materially  differ  from  a  simi- 
lar record  of  an  adult  case,  except  as  it  refers  to  certain  events  in 
the  child's  life  and  development.  But  whether  kept  by  book  or  card 
matters  little  as  long  as  the  record  is  complete  enough  to  act  as  such. 
Incomplete  records  may  be  harmful  as  well  as  being  unsatisfactory. 
The  card  system  will  prove  of  most  service,  as  the  cases  can  bo 
classed  not  alone  as  individual  ones,  but  at  the  time  when  the  diag- 
nosis is  positively  made  the  cards  may  be  classified  according  to  the 


GENERAL    HISTORY    TAKING 


13 


disease  or  injury  present.  The  card  which  we  have  found  of  most 
service  is  the  one  here  shown  (see  Figure  4),  and  as  it  is  of  con- 
venient size  (5x8  inches),  and  blank  upon  the  reverse  side,  it  allows 
of  the  free  use  of  rubber  stamps  which  outline  the  various  portions 
of  the  body.  The  use  of  such  stamps  is  a  great  time  saver  and  tends 
to  develop  accuracy. 

For  convenience  of  use  while  in  the  patient's  home  similar  data 
is  printed  upon  very  thin  but  good  paper  stock  and,  when  conveni- 
ent, this  is  pasted  upon  one  of  the  cards. 


Birth  Httlory 


Feeding  Hi; 


Referred  by  Dr. 


FIG.  4 — HISTORY  CARD. 

W.  C.  on  first  line  means  white  or  colored. 

Nat.   on  second  line  means  nationality. 

F.  M.  on  fourth  and  fifth  lines  refers  to  paternal  or  maternal  grandparents. 

The  feeding  history,  the  weight,  and  the  history  of  the  teeth  are  placed  so  that  a  ready 

comparison  can  be  made  of  these  as  associated  factors. 
The  reverse  side  is  blank  for  further  data  or  the  use  of  outline  stamps  indicating  the 

affected  portion  of  the  body. 

THE  HISTORY  OF  THE  PRESENT  ILLNESS  is  naturally  the  first 
thing  to  be  elicited,  and  this  is  best  done  by  a  single  leading  question 
put  to  the  parent,  as,  "Of  what  does  the  child  complain  ?"  Only 
under  exceptional  circumstances  should  there  be  any  interruption 
as  this  history  is  given.  Full  scope  should  be  allowed  the  parent  to 
tell  all  about  the  child's  condition  and  the  events  that  led  up  to  it, 


14  THE  EXAMINATION 

and  meanwhile  the  surgeon  should  be  studying  two  things.,  the  his- 
tory as  given,  and  the  temperament  of  the  one  who  is  giving  it. 
This  latter  is  quite  important,  as  there  is  a  tendency  in  some  to  en- 
large upon  the  illness  or  injury  or  to  exaggerate  particular  symp- 
toms: and,  upon  the  other  hand,  certain  important  ones  may  be 
underestimated  or  overlooked. 

The  larger  number  of  parents  deceive  the  surgeon  unintention- 
ally through  the  common  habit  of  the  loose  use  of  words  and  inac- 
curacy of  observation. 

In  order  to  excite  the  greater  interest  of  the  surgeon  or  from 
some  morbid  tendency  some  will  knowingly  exaggerate  all  of  the 
symptoms.  All  of  these  matters  must  be  given  consideration.  Lead- 
ing questions  must  be  absolutely  avoided. 

The  statement  as  regards  the  time  of  the  onset  will  immediately 
place  the  disease  in  one  of  two  categories — acute  or  chronic.  Never- 
theless, even  if  acute,  it  is  important  to  determine  beyond  any  reas- 
onable doubt  whether  it  is  dependent  upon  some  underlying  chronic 
condition.  From  this  an  endeavor  should  be  made  to  arrange  the 
subsequent  symptoms  in  the  order  of  their  occurrence  up  to  the  time 
of  examination,  and,  if  the  child  has  been  previously  the  subject  of 
surgical  intervention,  completeness  demands  that  the  procedure  pre- 
viously undertaken  be  fully  known. 

Upon  fixing  the  date  of  onset  there  will  arise  the  difficulties  at- 
tending upon  inaccurate  observation  of  the  parent.  For  instance,  a 
spinal  curvature  which  has  existed  for  months  may  not  have  been 
observed,  and  when  discovered  the  parent,  not  wishing  to  appear 
neglectful  or  unobserving, ,  states  that  it  is  of  recent  origin.  This 
inaccuracy  is  always  more  in  evidence  when  we  are  dealing  with 
swellings,  new  growths,  muscular  incoordinations,  and  gradually  de- 
veloped conditions. 

In  older  children  who  show  a  normal  degree  of  intelligence  a 
few  pointed  questions  put  to  the  child  will  prove  a  valuable  supple- 
ment to  the  history,  provided  that  the  parent  has  been  warned  against 
interrupting  the  child,  even  though  its  answers  do  not  completely 
coincide  with  the  parent's  history.  The  history  thus  obtained 
through  parent  and  child  will  be  in  every  instance  incomplete.  Dif- 


GENERAL    HISTORY    TAKING  15 

fereiit  methods  of  elucidation  will  suggest  themselves,  according  to 
the  temperament  and  intelligence  of  the  history-giver.  The  exam- 
iner must  recognize  the  fact  that  much  of  the  history  as  given  by 
the  child  is  influenced  by  its  own  chief  characteristics,  and  that  this 
is  also  true  of  the  parent's  history  giving.  Of  course,  in  cases  of 
accident  involving  possible  legal  complications,  another  undesirable 
element  is  added  which  greatly  affects  the  history  as  given.  The 
time  spent  in  obtaining  a  full  and  complete  account  of  the  child's 
present  and  previous  condition  is  never  wasted. 

It  is  not  necessary  that  the  history  be  given  in  strict  accordance 
with  the  occurrence  of  the  events ;  the  main  thing  is  that  the  surgeon 
have  in  his  own  mind  an  orderly  arrangement  of  the  events,  in  order 
to  arrive  at  the  fight  conclusions  as  to  what  events  require  further 
investigation.  It  may  be  necessary,  in  order  to  do  this,  to  ask  a  few 
pointed  but  not  leading  questions. 

THE  HISTORY  OF  THE  PREVIOUS  CONDITION  of  the  child  is  an 
important  one  in  surgery,  in  fact  more  so  than  in  medical  practice, 
because  the  operations  of  surgery  are  more  exact  and  there  is  less 
chance  for  error.  For  instance,  it  might  be  positively  stated  that  a 
child  had  suffered  from  scarlet  fever  when  the  true  condition  was 
simply  erythema  scarletiform,  and  this  is  always  misleading,  but  if 
there  was  a  history  of  appendicitis  with  surgical  relief  the  matter 
becomes  one  of  certainty. 

A  knowledge  of  all  of  the  diseases  from  which  the  child  may 
have  suffered  is  essential  in  history  taking  in  surgery,  provided  that 
a  fairly  accurate  account  of  the  nature,  the  date,  and  the  severity  of 
the  disease  can  be  obtained.  Previous  attacks  of  certain  diseases 
predispose  the  child  to  subsequent  attacks,  while,  on  the  other  hand, 
one  attack  offers  a  certain  amount  of  immunity  against  future  at- 
tacks. 

And,  again,  many  conditions  arise  simply  as  sequelae,  so  that  a 
history  of  the  primary  affection  throws  some  light  upon  the  immedi- 
ate condition.  But  here  again  the  surgeon  shares  with  the  internist 
the  trials  of  inaccurate  statements. 

For  the  purpose  of  obtaining  an  estimate  of  the  child's  power 
of  resistance  to  certain  diseases  and  its  ability  to  withstand  the  or- 


16  THE  EXAMINATION 

deal  of  a  possible  surgical  procedure  the  history  of  the  previous  con- 
dition must  take  cognizance  of  the  following:  Was  the  child  born 
at  full  term  or  abortive  ?  If  the  latter,  then  there  is  sufficient  reason 
for  the  little  one  remaining  weak  and  anemic  for  a  long  time.  An 
abortive  infant  is  always  more  susceptible  to  all  of  the  infections 
and  shows  a  decided  tendency  to  become  rachitic.  The  vital  resist- 
ance of  such  children  is  always  much  lower  and  more  easily  disturbed 
than  the  normal. 

However,  if  there  is  a  tardy  development  without  a  recognized 
cause  or  occurring  as  the  result  of  a  recognized  etiology,  but  out  of 
all  proportion  to  that  cause,  it  should  at  least  suggest  the  possibility 
of  syphilis. 

The  same  is  true  of  a  rachitic  type  of  skull  developed  in  a  child 

without  the  other  evidences  of 
rachitis  (as  beaded  ribs,  baldness 
of  occiput,  head  sweating,  flabby 
musculature,  anemia,  etc.)  being 
present  or  proportionately 
marked.  A  history  of  the  abor- 
tive habit  in  the  mother  would 
always  suggest  the  probability  of 
syphilis. 
FIG.  5.— RACHITIC  TYPE  OF  SKULL.  Was  the  delivery  of  the  in- 

(Note  especially  the  flattened  vertex)  <•  i     i         •  i    ' 

fant  attended  with  difficulty  or 

the  labor  protracted  ?  If  so,  this  might  account  for  a  subsequent  epi- 
lepsy or  mental  deficiency  or,  if  very  difficult  but  not  necessarily 
protracted,  for  spastic  hemiplegia  and  other  nervous  diseases. 

How  was  the  child  fed?  This  question  is  important  as  an  indi- 
cator of  the  probable  power  of  resistance  which  the  child  may  h;m> 
and,  combined  with  the  next  question,  "When  and  how  were  the  teeth 
erupted  ?"  gives  a  good  clew  to  the  discovery  of  a  rachitic  condition. 

The  average  order  and  time  of  appearance  of  the  teeth  is  as  fol- 
lows: 

Between  six  and  eight  months,  the  two  lower  central  incisors. 
Two  months  later,  the  four  upper  incisors. 


SECURING  CHILD'S  CONFIDENCE  IT 

Four  months  later,  two  lower  lateral  incisors  and  four  anterior 
molars. 

Six  months  later,  the  four  canines. 

In  another  six  months,  the  four  posterior  molars. 

Speaking  generally,  the  deviation  from  the  average  in  teethinc; 
is  an  indication  of  the  general  nutrition  of  the  child.  There  may 
be  normally  some  variation  in  the  time  of  the  appearance  of  the  first 
teeth  (the  two  lower  central  incisors),  but  after  their  appearance 
there  should  be  a  quite  constant  regularity  in  the  order  of  the  erup- 
tion of  the  other  teeth. 

If  the  child  is  one  of  several  in  a  family  it  is  necessary  to  know 
something  of  the  general  condition  and  history  of  the  brothers  and 


FIG.  6. — THE  TEETH  BETWEEN  Six 
AND  EIGHT   MONTHS. 


FIG.  7. — THE    TEETH    Two     MONTHS 

AFTER     THE     APPEARANCE     OF     THE 

Two  LOWER  CENTRAL  INCISORS. 


sisters  and,  in  case  any  have  died,  to  learn  the  cause  of  death. 
Where  the  family  is  large  inquiry  must  be  made  as  to  the  intervals 
between  births,  as  rapidly  recurring  pregnancies  exhaust  the  mother 
and  have  a  decided  influence  upon  the  physical  condition  of  each 
succeeding  child. 

Any  history  of  the  tendency  of  the  children  of  a  family  to  suffer 
from  unaccountable  anemias  and  malnutrition  during  the  earlier 
periods  of  life,  despite  the  fact  that  the  hygienic  surroundings  and 
the  dietetic  care  are  both  excellent,  or  the  occurrence  of  anomalous 
types  of  disease  in  two  or  more  children  of  a  family  should  arouse 
a  suspicion  of  syphilis. 

Securing  Child's  Confidence. — The  securing  of  the  cooperation  and 


18 


THE  EXAMINATION 


confidence  of  the  child  depends  almost  entirely  upon  the  tact  and 
firmness  of  the  surgeon  with  a  knowledge  of  the  child's  chief  char- 
acteristics and  an  appeal  to  these  latter. 

Activity  is  one  of  the  most  prominent  characteristics  in  early 
life.  The  child  is  naturally  restless  and  rebels  against  restraint 
which  extends  over  long  periods.  Added  to  this,  is  an  inability  to 
concentrate  the  thoughts  for  more  than  a  short  time.  This  restless- 
ness is  Nature's  method  of  preventing  a  one-sided  development.  The 
child,  being  incapable  of  lengthy  concentration  or  repose,  makes  a 
demand  for  variety  and  frequent  change.  The  examiner  must  take 
cognizance  of  this  characteristic  and  plan  his  examination  so  that 


FIG.  8. — THE  TEETH  BETWEEN  THE 
TWELFTH  AND  FOURTEENTH 
MONTHS. 


FIG.  9. — THE   TEETH    BETWEEN  THE 
SIXTEENTH  AND  TWENTY-SECOND 
.    MONTHS. 


change  of  posture  and  of  the  details  may  be  frequent  enough  to 
secure  the  child's  interest  and  cooperation. 

While  incapable  of  prolonged  concentration  the  characteristic 
of  attention  is  so  strong  in  childhood  that  there  is  often  an  inability 
to  avoid  interest  in  things  which  are  presented  to  the  child's  atten- 
tion. This  is  true  in  part  chiefly  because  curiosity  is  so  prominent 
at  this  period  in  life.  The  child  usually  gives  its  attention  instinc- 
tively and  without  any  effort  of  the  will.  A  knowledge  of  this  char- 
acteristic will  prove  most  helpful  in  securing  relaxation  of  muscles 
or  helping  in  a  proper  estimate  of  the  degree  of  tenderness  present  in 
a  tender  or  painful  part. 

Imagination  is  most  vivid  in  early  childhood,  and  advantage  can 
be  taken  of  this  to  secure  a  considerable  degree  of  cooperation.  It  is 
this  same  characteristic  of  imagination  that  becomes  a  large  factor  in 


SECURING  CHILD'S  CONFIDENCE 


19 


making  examinations  in  children  difficult.  Often  the  characteristic 
has  been  misguided  and  advantage  has  been  taken  of  it  to  frighten 
children  into  a  semblance  of  obedience.  Commonly,  the  physician 
has  been  held  up  as  one  to  be  feared,  and  the  child  comes  to  the  ex- 
amination table  with  a  long-established  dread  of  the  examiner,  who- 
ever he  may  be. 

But  the  characteristic  is  so  strong  that  for  the  moment  the  sur- 
geon is  commonly  able  with  tact  to  so  strongly  excite  it  that  the 
usual  fear  and  dread  is  overcome  and  for  the  time  the  child  is  sub- 
missive. A  few  simple  lines  upon  a  piece  of  paper  will  readily  be 
transformed  by  the  imagination  of  the  child  into  real  persons  or 
things  when  the  suggestion  comes  from  the  one  who  draws  the  lines. 

There  are  some^very  practical 
points  that  it  is  well  for  all  exam- 
iners of  children  to  remember. 

(1)  KTo    child's    confidence    is 
ever  gained  by  deception.     If  the 
procedure  about  to  be  undertaken 
is  one  that  will  be  painful  it   is 
best  to  state  that  fact,  coincident 
with  the  beginning  of  the  proced- 
ure.    In  some  children  it  is  advis- 
able to  withhold  any  statement  as  to  the  possibility  of  causing  discom- 
fort, as  their  dread  of  pain  is  more  than  their  actual  experience  of 
it.    In  such  cases  we  must  proceed  immediately  with  the  examination. 
But  saying  to  a  child  of  ordinary  intelligence  "It  will  not  hurt," 
when  we  are  assured  that  the  procedure  about  to  be  undertaken  will 
or  may  cause  discomfort,  is  at  once  destructive  of  the  child's  confi- 
dence and  must  be  avoided.    It  is  the  child's  confidence  and  coopera- 
tion that  we  seek,  and  these  are  never  gained  except  by  frankness  and 
firmness. 

(2)  Begin  with  the  simplest  procedure  and  delay  the  more  pain- 
ful or  terrifying  ones  until  the  last. 

(3)  Do  not  expect  relaxation  of  muscles  by  request;  divert  the 
child's  attention  and  secure  it  in  that  way. 

(4)  Every  child  must  know  that  the  examiner  is  master  of  the 


FIG.  10. — THE  TEETH  BETWEEN  THE 
TWENTY-SECOND  AND  THE  TWENTY- 
EIGHTH  MONTHS. 


20  .     THE  EXAMINATION 

situation.  We  may  have  to  use  very  different  methods  in  our  ap- 
proach to  the  child,  according  to  their  age,  temperament,  present 
condition,  and  past  training  and  environment,  but  these  do  not  in- 
fluence the  necessity  of  having  every  child  feel  instinctively  that  for 
the  time  he  or  she  is  under  the  domination  of  a  higher  will. 

(5)  Do  not  add  to  your  office  armamentarium  expensive  toy.s  or 
articles  which  cannot  be  carried  away  by  the  child.  Children  have 
an  easily  aroused  sense  of  injustice,  and  if  a  toy  is  given  to  secure 
cooperation  and  then  when  the  examination  is  over  the  toy  is  taken 
away,  the  child  justly  rebels  and  the  confidence  thus  once  destroyed 
is  hard  to  secure  at  subsequent  examinations. 

And  there  is  another  danger  of  the  expensive  toy.  Any  child 
may  be  the  subject  of  an  infectious  or  contagious  disease,  and  the 
retention  of  the  handled  toy  in  the  office  of  the  surgeon  invites  dis- 
aster to  the  following  patients.  Sanitation  and  good  sense  demand 
the  use  of  the  inexpensive  attention  holder. 

THE  APPROACH  TO  THE  CHILD  may  have  to  be  in  many  instances 
very  gradual,  and  the  examiner  must  remember  that  he  is  dealing 
with  an  irrational,  easily  frightened  being,  whose  disease  has  un- 
doubtedly irritated  or  exhausted  it  to  such  an  extent  that  it  lacks 
entire  self-control. 

It  is  hardly  necessary,  therefore,  to  state  that  before  a  successful 
examination  can  be  made  the  examiner  and  the  child  must  under- 
stand each  other.  There  can  be  no  hard  and  fast  rules  by  which  we 
may  hope  to  win  the  confidence  of  the  child ;  one  will  require  to  be 
absolutely  ignored  for  the  time  being  while  a  history  of  the  condi- 
tion is  being  obtained;  another  must  be  approached  at  once.  AViili 
a  child  of  this  latter  class  it  is  best  for  the  surgeon  to  retire  from 
the  room  at  the  first  sign  of  rebellion  at  his  presence,  and  obtain  the 
full  history  of  the  case,  after  which  the  approach  must  be  firm  to 
conVince  the  child  that  the  surgeon  is  the  master  of  the  situation. 

In  dealing  with  older  children  the  object  may  be  obtained  by 
drawing  the  child  into  a  conversation,  and  this  is  best  done  by  im- 
personal questioning.  But  no  replies  must  be  expected  from  such 
questioning,  for  a  child  that  is  timid  usually  does  not  talk,  and  if 
pressed  for  a  reply  the  shyness  is  increased.  The  real  object  of  the 


SIDE    POSITION"  21 

remarks  to  the  child  is  to  impel  him  to  join  in  and  through  this 
opening  to  gain  his  confidence.  If  the  conversation  is  about  the 
things  in  which  he  is  vitally  interested  it  will  be  but  a  few  moments 
before  he  is  compelled  by  his  own  interest  to  join  in  with  the  ex- 
aminer, who  is  then  well  on  the  road  to  the  securing  of  the  little  one's 
confidence. 

Of  course,  in  the  instance  of  the  "spoiled  child,"  there  is  no 
possibility  of  gaining  its  confidence  or  cooperation,  except  after  a 
very  long  season  of  contact.  Such  a  child's  confidence  and  trust  in 
any  one  have  been  almost  completely  destroyed.  These  unfortunates 
have  never  been  brought  under  the  influence  of  authority,  and  are 
always  the  product  of  bad  training.  They  must  of  necessity  be 
dealt  with  firmly  and  forcibly,  and  not  in  the  presence  of  their 
parents. 

CHAPTER  IV 

GENERAL  POSTURE 

The  position  which  a  child  assumes  while  in  bed  is  often  sug- 
gestive. The  attitude  of  the  child  may,  on  the  one  hand,  be  reassur- 
ing, as  we  note  that  he  lies  quietly  and  rests  easily  and  sits  up  or 
turns  to  greet  the  surgeon.  It  assures  one  that  the  disease  or  injury 
is  probably  slight,  or  that  convalescence  is  already  established.  When 
the  child  becomes  muscularly  and  mentally  inactive  we  may  be  sure 
that  the  illness  or  injury  is  severe.  In  fact,  the  disinclination  to 
continue  muscular  activity  should  always  be  interpreted  as  an  early 
sign  of  ill  health,  and  this  is  often  expressed  by  the  child  in  the  de- 
sire to  be  left  undisturbed.  The  common  accompaniment  of  dimin- 
ished muscular  activity  is  a  diminution  of  mental  activity,  and  the 
child  loses  interest  in  its  surroundings  and  playmates  because  the 
exertion  demanded  by  the  attentive  attitude  is  unpleasant. 

Side  Position.  — The  side  position  is  assumed  characteristically  in 
acute  pleurisy  until  the  time  of  effusion,  and  then  there  is  often  a 
change  to  the  dorsal.  If  a  child  is  pale  and  thin,  indicating  that  the 
illness  has  been  a  long  one,  and  the  breathing  is  much  interfered 


22 


GENERAL  POSTURE 


with,  we  may  be  almost  certain  that  there  is  a  large  exudate.     A 
light  percussion  would  be  sufficient  to  exclude  pneumothorax. 


FIQ.  11. — SIDE  POSTURE  CHARACTERISTICALLY  ASSUMED  IN  PAINFUL  CONDITIONS  OF  THE 
CHEST  AND  SOMETIMES  WHEN  ONE  SIDE  OF  THE  ABDOMEN  is  AFFECTED. 

Dorsal  Position. — The  dorsal  position  (a)  with  slightly  flexed 
legs,  is  the  position  of  election  in  cases  of  acute  peritonitis  and 
tuberculous  peritonitis.  Motion  is  carefully  avoided,  and  in  acute 


FIG.  12. — DORSAL  POSTURE,  WHICH  is  THE  POSTURE  ASSUMED  BT  THE  CHILD  MOST 
OFTEN  IN  PERITONITIS,  PERINEPHRITIS,  APPENDICITIS. 

peritonitis  there  is  usually  an  expressed  fear  as  the  child  is  ap- 
proached. 

(b)  With  a  curve  of  the  body  slightly  toward  the  right  side,  and 


ON    THE    ABDOMEN 


with  the  right  knee  more  or  less  flexed,  the  dorsal  position  is  as- 
sumed in  appendicitis  if  pain  or  tenderness  are  prominent  features. 
Sometimes  the  child  will  hold  the  knee,  but  this  should  not  distract 
the  surgeon's  attention  from  the  real  site  of  trouble,  which  is  within 
the  abdomen. 

(c)  With  the  thighs  and  also  the  knees  flexed  and  more  or  less 
rigidity  of  the  leg  of  the  affected  side  the  dorsal  posture  is  assumed 
in  perinephritis,  but  is  a  rather  late  occurrence.  Preceding  this 
there  is  the  assumption  of  the  position  of  slight  flexion  of  the  body 
toward  the  affected  side  and  some  flexion  of  the  knee  and  hip.  In 
standing  the  child  may  place  the  hand  upon  the  knee  of  the  affected 
side  or  slightly  above  it.  This  posture  is  assumed  in  lumbar  disease 
of  the  spine,  also,  and  these  must  be  differentiated. 


FIG.  13. — POSTURK  "ON  THE  ABDOMEN." 

The  child  usually  does  not  lie  flat   on   the   abdomen  for   any  length  of  time,  but  re- 
mains partly  in  that  posture  for  protracted  periods. 

(d)  With  the  affected  limb  held  more  or  less  rigid  and  flexed  to 
relieve  the  tension  in  acute  infective  tenosynovitis  and  in  scurvy 
when  epiphyseal  separation  has  occurred  or  is  threatening. 

But  it  must  not  be  forgotten  by  the  surgeon  that  in  children  a 
full  bladder  or  the  occurrence  of  a  hernia  (even  of  a  mild  degree) 
will  compel  the  child  not  infrequently  to  assume  the  dorsal  posture. 

(e)  If  a  child  suffering  from  pleurisy  and  assuming  the  char- 
acteristic side  position  changes  that  posture  to  a  prolonged  dorsal  one 
it  is  suggestive  of  effusion. 

On  the  Abdomen. — On  the  abdomen  is  the  position  taken  in:  (a) 


24  THE  GAIT 

some  cases  of  Pott's  disease,  but  in  this  it  is  by  no  means  character- 
istic. 

(b)  In  phlegmons  of  the  back  (to  relieve  the  pain  from  undue 
pressure). 

(c)  To  secure  the  relief  which  is  occasioned  by  pressure  in  non- 
inflammatory conditions  of  the  abdomen. 

Forced  Positions. — Forced  positions  are  those  which  are  assumed 
in  certain  diseases  as  tetanus,  meningitis,  etc.,  and  which  are  ex- 
hibited as  opisthotonos  and  emprosthotonos. 

Upright  Position. — The  upright  position  may  be  assumed  as  the 
result  of  accumulations  of  fluid  within  the  abdomen  interfering  with 
respiration,  from  large  effusions  in  the  pericardial  or  pleural  cav- 
ities, or  from  hypcrthyroidism. 

Constantly  Changed  Position. — Constant  changing  of  position  is 
indicative  of  pain  and  irritation,  and  if  the  legs  are  alternately 
drawn  up  and  down  and  the  arms  thrown  about  the  probability  is 
that  inflammation  is  not  present  in  any  marked  degree. 


CHAPTER  V 

THE  GAIT 

Limping.  — If  the  child  limps  even  slightly  the  cause  should  be 
determined  at  once,  and  it  must  never  be  dismissed  as  a  trivial 
symptom.  The  examination  to  determine  the  cause  should  be  made 
with  the  child  nude.  It  is  an  easy  matter  to  attribute  most  of  the 
instances  of  limp  to  rheumatism  as  the  cause,  and  without  the  most 
careful  questioning  the  surgeon  can  be  readily  led  into  error  by  the 
history  as  given  by  the  parent.  But  we  must  be  ever  mindful  of 
the  fact  that  countless  errors  have  been  made  in  attributing  most 
limps  to  rheumatism,  and  the  attitude  of  the  surgeon  must  con- 
stantly be  that  the  diagnosis  of  rheumatism  in  children  should  not 
be  made  until  every  other  possible  cause  for  the  symptoms  has  been 
excluded.  In  a  large  number  of  the  instances  the  true  cause  of  the 
limp  will  be  found  in  muscular  rigidity  consequent  upon  inflamma- 


WADDLING  25 

tory  bone  disease.  This  is  true,  irrespective  of  the  presence  or  ab- 
sence of  pain  as  expressed  by  the  child.  In  the  large  majority  of 
instances  the  cause  of  the  limp  will  be  found  in  an  incipient  tubercu- 
lous or  inflammatory  bone  disease  of  the  spine,  the  hip,  the  knee,  or 
other  joint.  The  first  condition  is  usually  one  of  muscular  rigidity, 
and  this  in  itself  may  create  the  limp,  and  yet  the  child  may  not 
be  conscious  of  pain.  Limping  from  rheumatism  is  not  long  con- 
tinued. That  is,  rheumatism  has  as  one  of  its  characteristics  in 
childhood  the  marked  tendency  to  be  non-arthritic  in  its  manifesta- 
tions, but  cardiovascular.  When  arthritic  symptoms  are  present  it 
is  very  unusual  for  a  particular  joint  to  be  affected  for  more  than 
two  or  three  days.  Then  other  joints  may  become  affected  in  suc- 
cession. From  this  it  will  be  observed  that  a  persistent  limp  would 
not  be  at  all  suggestive  of  rheumatism,  unless  in  those  rarer  in- 
stances in  which  deformity  has  taken  place.  The  characteristic  limp- 
ing in  tuberculous  hip  disease  is  a  decided  prolongation  of  the  nor- 
mal time  in  which  the  affected  leg  is  made  to  bear  the  weight  of  the 
body.  This  by  observation  gives  a  gait  which  is  quite  uneven  and 
with  some  slight  dragging  of  the  affected  member.  However,  if  the . 
disease  has  already  caused  deformity,  there  will  be  a  very  decided 
limp,  because  the  leg  is  then  held  in  abnormal  relation  to  the  pelvis. 
Intermittent  limping  is  often  observed  in  the  earlier  stages  of  joint 
disease,  but  its  most  characteristic  appearance  is  in  those  cases  in 
which  there  is  an  obstructive  interference  with  the  circulation  of  the 
lower  limbs.  This  interference  comes  from  thickened  arteries;  in 
other  words,  there  is  a  true  arterial  sclerosis  of  the  legs.  While  not 
common,  yet  it  occasionally  appears  during  childhood  and  may  result 
in  gangrene.  The  pain  is  most  commonly  complained  of  at  the  hip 
or  in  the  calf,  and  is  aggravated  by  exercise.  Pulsation  of  the 
arteries  of  the  foot  is  diminished  and  the  whole  foot  may  assume  a 
white  or  bluish  hue  and  become  cold.  The  etiology  is  uncertain,  but 
syphilis  has  been  associated  in  most  instances  which  have  been 
studied.  Rest  in  bed  or  by  crutches  is  the  treatment  plus  the  treat- 
ment of  the  exciting  cause  (as  syphilis)  if  that  can  be  reasonably 
determined. 

Waddling. — While  the  first  thing  that  is  forcibly  brought  to  the 


26  PAIN 

attention  in  children  who  suffer  from  congenital  dislocation  is  that 
they  walk  late,  still  it  is  evident  that  from  the  time  the  first  steps 
are  taken  the  gait  is  uncertain  and  staggering.  In  cases  of  double 
dislocation  there  appears  the  very  characteristic  "waddling"  walk. 

However,  this  type  of  walking  is  closely  approximated  by  some 
cases  of  rachitis.  If  the  surgeon  finds  that  there  exist  the  usual  de- 
formities of  the  limbs  as  observed  in  rachitis,  such  as  the  curved 
tibiae,  the  epiphyseal  swellings,  etc.,  this  is  not  sufficient  evidence  to 
establish  the  diagnosis  of  rachitis.  Cases  of  congenital  dislocation 
frequently  exhibit  just  such  deformity,  and  a  most  searching  ex- 
amination is  necessary  to  establish  the  diagnosis  definitely. 

Stumbling  Gait. — In  flat-foot  the  inability  to  dorsiflex  the  ankle 
beyond  the  right  angle  results  in  a  stumbling  or  awkward  gait  which 
is  especially  noticeable  when  the  child  runs,  because  there  occurs  a 
spastic  contraction  of  the  calf  muscles.  The  child  generally  walks 
with  much  shortened  steps,  bent  knees,  and  the  feet  everted. 

Sooner  or  later  to  every  surgeon  who  deals  largely  with  children 
will  come  patients  with  a  history  of  injury  of  the  knee  followed  ap- 
parently weeks  or  months  later  by  swelling,  effusion,  and  disability. 
While  all  evidences  of  the  traumatism  have  usually  disappeared, 
still  the  immediate  pathological  condition  at  the  time  of  examina- 
tion may  be  anything  from  a  sensitive  joint  to  a  tuberculous  process 
or  a  sarcoma. 

This  always  results  in  some  interference  with  the  free  use  of  the 
limb,  and  there  is  a  consequent  limp  which  is  persistent  and  usually 
progressive. 

CHAPTEK   VI 

PAIN 

GENERAL   CONSIDERATIONS 

Pain  is  very  difficult  of  recognition  in  infancy  because  many  of 
the  notable  features  which  usually  accompany  it  are  present  in  con- 
ditions in  which  no  pain  is  appreciated.  (Some  of  these  features 


GENERAL    CONSIDERATIONS  27 

are  the  tense  pulse,  hurried  respirations,  drawn  features,  restless- 
ness, etc.) 

Being  a  purely  subjective  symptom,  its  intensity  as  well  as  its 
presence  must  often  be  determined  by  observation,  by  the  nature  and 
extent  of  the  probable  cause,  and  the  statements  of  the  child  or  its 
parent. 

Even  in  children  of  considerable  age  and  intelligence  the  recog- 
nition of  pain  and  its  intensity  must  be  substantiated  by  other  evi- 
dences than  the  statements  of  child  or  parent. 

When  the  child  is  too  taciturn,  exaggerates,  or  is  in  any  way 
incapable  of  accurately  describing  the  sensation  of  pain,  we  must  rely 
more  upon  the  objective  evidences. 

By  far  the  largest  factor  in  the  proper  estimation  of  pain  in 
children,  and  an  appreciation  of  its  intensity  and  character,  comes 
from  the  inability  of  the  examiner  to  correctly  gage  individual 
susceptibility,  and  this  can  never  be  learned  from  books.  There  are 
marked  differences  among  children  in  the  susceptibility  to  pain 
perception,  and  this  is  further  modified  by  nutritional  conditions 
existent  at  the  time  or  shortly  antedating  it.  Long-continued  pain 
leaves  the  child  less  resistant  and  therefore  actual  pain  at  the  time  of 
examination  seems  much  exaggerated. 

Tenderness  should  not  be  confounded  with  pain.  It  is  the  product 
of  painful  sensations  through  the  agency  of  pressure,  and  pain  is 
usually  associated  with  tenderness.  In  diagnosis  it  is  well  to  recall 
that  pressure  over  the  part  complained  of  by  the  child  as  being  the 
actual  site  of  pain  may  reveal  no  tenderness,  while  pressure  over  a 
more  distant  and  uncomplained  of  part  may  show  the  real  point  of 
invasion. 

Mode  of  Onset. — The  mode  of  onset  is  indicative  of  the  acuteness 
of  the  causative  factor ;  sudden  onset  or  short  duration  indicating  an 
acute  condition  and  gradually  developed  or  prolonged  pain  indicat- 
ing chronicity  and  no  solution  of  continuity. 

Time  of  Occurrence. — The  time  of  occurrence  has  some  value. 
For  instance,  headaches  occurring  in  the  late  afternoon  are  almost 
always  due  to  anemia  or  a  weakened  heart  action.  Pain  at  night  is 
always  suggestive  of  periosteal  inflammation.  Pain  immediately 


28  PAIN 

following  a  meal  would  be  suggestive  of  a  digestive  fault  and,  if 
occurring  somewhat  later  and  referred  to  the  abdomen,  then  of  an 
intestinal  one.  Then,  again,  we  may  have  the  pain  referred  to  some 
functional  act,  and  its  increase  or  occurrence  persistently  with  the 
acts  of  respiration,  urination,  deglutition,  defecation,  and  so  forth, 
would  indicate  the  true  cause. 

Character  of  the  Pain. — If  the  child  be  intelligent  enough  to  dis- 
tinguish the  character  of  the  pain  there  may  be  some  value  in  de- 
termining this  point,  for  it  is  often  indicative  of  the  cause. 

(a)  An  acute,  stabbing  pain  is  usually  observed  in  the  acute 
inflammations.     If  radiating  it  is  suggestive  of  neuralgia  or  neu- 
ritis. 

(b)  Dull  pain  occurs  mostly  as  the  result  of  inflammations  in  the 
mucous  membranes,  the  parenchymatous  viscera,  or  when  inflamma- 
tion has  been  of  long  standing.     It  is  also  observed  in  visceral  af- 
fections and  injuries. 

(c)  Constant  and  boring  pain  is  observed  in  affections  of  the 
bones  and  in  periosteal  disease.     The  pain  of  hip  joint  disease  is  an 
early  but  by  no  means  a  constant  symptom,  and  in  most  instances 
the  pain  is  much  worse  at  night.     It  may  be  referred  to  the  knee  of 
the  affected  side. 

(d)  Aching  pain  or  soreness  indicates  that  the  affection  is  in  the 
musculature,  although  the  underlying  cause  may  be  constitutional. 

(e)  Burning  and  itching  pain  is  most  commonly  observed  in  the 
various  skin  affections. 

(f)  Remitting  pain  is  suggestive  and  characteristic  of  colic,  of 
some  cases  of  neuralgia,  and  cramps  of  all  kinds. 

(g)  Pain  increased  by  motion  is  observed  in  all  inflammatory 
processes,  in  diseases  of  the  bones  and  joints  (in  which  it  is  usually 
dependent  upon  muscular  spasm),  and  particularly  and  character- 
istically in  scurvy  and  rachitis.     In  fact,  in  scurvy,  it  is  a  very  com- 
mon experience  to  find  that  the  very  first  symptom  which  calls  at- 
tention to  the  fact  that  the  child  is  not  well  is  the  history  of  evident 
pain  upon  handling,  and  this  may  have  persisted  for  a  considerable 
time  before  other  symptoms  are  noted. 

Site  of  the  Pain. — In  children  the  site  of  the  pain  does  not  al- 


GENERAL    CONSIDERATIONS 


ways  correspond  with  the  situation  of  the  causative  factor.  It  is 
always  well  for  the  surgeon  to  remember  that  pain  in  children  cor- 
responds only  to  nerve  distribution,  so  that  when  an  organ  or  part 
is  affected  with  disease  the  pain  is  sometimes  referred  to  that  situa- 
tion, but  is  more  commonly  referred  to  points  somewhat  distant  but 
in  line  with  the  nerve  distribution  from  the  diseased  part.  For 
instance,  the  referred  pain  due  to 
Pott's  disease  has  been  the  occasion 
for  a  considerable  amount  of  error. 
I  Deferred  to  the  abdomen,  it  has  often 
given  rise  to  the  suspicion  of  digest- 
ive trouble;  to  the  chest,  it  has  occa- 
sioned a  diagnosis  of  pleurisy. 

GENERALLY  DIFFUSED  PAIN  occurs 
quite  constantly  in  children  in  all  the 
febrile  processes,  and  particularly 
those  with  an  infectious  etiology, 
so  that  its  diagnostic  import  is  quite 
small. 

PAIN  IN  THE  LATERAL  WALL  OF 
THE  CHEST. — This  has  as  its  most 
common  causes  pleurisy,  intercostal 
neuralgia,  enlarged  bronchial  glands, 
vertebral  disease,  pneumonia,  and  dis- 
eases and  injuries  of  the  chest  wall. 

PA IX   IN   THE  PRECORDIAL  REGION 

is  usually  due  to  gastralgia,  pericar- 
ditis (rare  in  children). 

PAIN  ABOUT  THE  DIAPHRAGM  may 
persist  for  several  hours  after  severe 
vomiting   or    prolonged    coughing,    and    is    commonly   observed    in 
pl(  urisy. 

EPIGASTRIC  PAIN  generally  depends  for  its  cause  upon  some  one 
of  the  gastric  neuroses,  gastric  inflammation,  vertebral  disease,  or 
pneumonia,  or  may  be  due  to  acute  gastric  dilatation. 

PAIN  IN  THE  UPPER  EXTREMITY  is  most  commonly  due  to  neu- 


FIG.  14. — PAIN     IN     THE     LATERAL 
WALL  OF  THE  CHEST. 

Most  commonly  present  in  pleurisy, 
enlarged  bronchial  glands,  inter- 
costal neuralgia,  vertebral  dis- 
ease, pneumonia  and  chest  in- 
juries. 


30 


PAIN 


ritis,  enlarged  axillary  glands,  and  to  bone  disease.     Confined  strictly 
to  the  left  arm,  it  is  observed  frequently  with  enlarged  spleen. 

BILATERAL  PAIN  IN  THE  AKMS  is  usually  of  central  origin,  or 
may  be  due  to  vertebral  disease. 

SPINAL  PAIN  is  complained  of  most  often  in  spinal  curvature, 
vertebral  disease,  diseases  of  the  meninges  (associated  with  muscular 
spasm),  and  in  many  cases  of  rachitis  and  scurvy  (in  which  it  closely 

simulates  the  pain  due  to 
organic  disease). 

PAIN    IN    THE    LOWER 

EXTREMITY  is  usually 
due  to  hip  joint  disease 
(usually  referred  to  the 
knee),  psoas  abscess,  peri- 
nephritis,  sciatica,  or,  less 
commonly  than  is  usually 
supposed,  to  rheumatism. 
In  fact,  every  other  pos- 
sible cause  for  pain 
should  be  eliminated  be- 
fore a  diagnosis  of  rheu- 
matism is  made  in  a 
child.  Pain  is  not  one  of 
the  prominent  features  of 
rheumatism  in  children. 
Pain  referred  to  a  joint 
may  be  due  to  synovitis, 
osteomyelitis,  tuberculous 
bone  disease,  scurvy,  or 
rheumatism.  In  some  rare  instances  rachitis  may  cause  such  pain. 
PAIN  IN  THE  EAR  is  almost  always  due  to  acute  otitis  or  to  mas- 
toiditis. 

PAIN  IN  THE  ABDOMEN,  the  HEAD,  and  in  the  EAR  are  very  im- 
portant symptoms  during  infancy  and  childhood,  and  therefore  they 
have  been  considered  somewhat  fully  in  separate  sections.  (See 
Abdominal  Pain,  page  31;  Headache,  page  40;  Earache,  page  42.) 


FIG.   15. — PAIN  IN  THE  EPIGASTRIUM. 
Most  often   present   in   pneumonia,    the   gastric   neu- 
roses, gastric  inflammation  and  acute  gastric  dil- 
atation. 


THE    SURGICAL    SIGNIFICANCE    OF    PA IX  31 

It  is  almost  impossible  and  quite  unnecessary  to  refer  in  detail  to 
all  of  the  conditions  which  in  childhood  will  cause  pain,  therefore 
all  that  we  have  considered  as  essential  was  a  reference  to  some  of 
the  more  important  causes  of  pain,  and  particularly  those  with 
which  the  surgeon  will  commonly  come  in  contact  in  children. 

THE*  SURGICAL   SIGNIFICANCE    OF    PAIN 

Abdominal  Pain. — It  requires  considerable  judgment  to  give  ab- 
dominal pain  in  the  child  its  proper  interpretation.  In  the  exam- 
ination of  the  older  child  it  is  necessary  to  determine  at  the  outset 
whether  or  not  the  pain  is  limited  to  the  abdominal  wall,  or  if  it  is 
associated  with  one  of  the  underlying  viscera. 

While  it  is  not  very  common,  at  the  same  time  it  is  not  infre- 
quent that  we  find  the  wall  of  the  abdomen  hyperesthetic.  The 
result  is  that  in  the  examination  to  determine  the  site  of  any  ab- 
dominal pain  the  inner  aspect  of  the  thighs  should  be  first  exam- 
ined. In  doing  this  we  gain  two  things :  first,  we  do  not  directly 
approach  the  site  of  expressed  pain,  and  we  thereby  gain  the  child's 
confidence  somewhat ;  and,  second,  hyperesthesia  of  the  abdominal 
wall  is  almost  invariably  associated  with  a  similar  condition  of  the 
inner  aspect  of  the  thighs,  and  absence  in  this  situation  would  lead 
one  to  suspect  its  absence  in  the  abdomen. 

When  such  hyperesthesia  is  present  it  is  spread  over  a  somewhat 
considerable  area,  extending  well  up  over  the  chest.  If  a  fold  of  the 
skin  is  grasped  and  firm  pressure  is  made  upon  it  the  pain  is  in- 
creased in  proportion  to  the  degree  of  pressure.  Hyperesthesia  of 
the  skin  of  the  abdomen  is  fairly  constantly  associated  with  typhoid 
fever  and  meningitis ;  less  frequently  with  malaria,  the  other  acute 
infectious  diseases,  and  anemia. 

Sometimes  we  find  that  the  pain  is  simply  muscular,  and  the 
causes  of  such  a  condition  are  usually  exposure  to  cold,  straining 
from  violent  coughing,  unusual  exercises  involving  the  abdominal 
musculature,  and  in  rare  instances  rheumatism.  In  all  such  cases 
the  pain  is  localized  quite  strictly  to  the  rccti  muscles  if  the  active 
cause  is  a  mild  one. 


32  PAIN 

However,  if  the  condition  is  of  the  unusual  severe  type,  there 
may  be  vomiting,  some  fever,  and  rather  widespread  abdominal 
pain,  which  compels  the  child  to  assume  one  position  and  remain  in 
it.  The  whole  course  of  the  severest  attacks  is  not  over  forty-eight 
hours.  In  nearly  every  instance  exercise  is  the  cause  of  the  severe 
attacks. 

If  the  pain  is  due  to  inflammation  of  the  peritoneum  it  is  by  far 
the  most  acute  abdominal  pain  which  is  observed.  It  is  continuous, 
although  this  fact  may  be  overlooked,  owing  to  the  acute  exacerba- 
tions which  occur,  and  which  are  due  to  peristalsis.  Associated  with 
the  pain  there  is  tension  of  the  abdominal  wall,  the  slightest  pressure 
increases  the  pain  markedly  and  makes  the  tension  more  prominent, 
and  there  are  the  other  evidences  of  inflammation  of  the  peritoneum, 
as  tympanites,  constipation,  etc. 

INTESTINAL,  COLIC  is  one  of  the  most  frequent  causes  of  pain 
and  crying  in  infants.  They  not  only  cry,  but  usually  there  is  a 
succession  of  shrieks,  which  is  associated  with  throwing  about  of  the 
legs,  until  relief  comes  with  the  expulsion  of  flatus.  Generally  such 
attacks  are  associated  with  constipation,  but  this  is  not  always  the 
case;  they  are  not  infrequently  associated  with  diarrhea.  An  im- 
portant aid  in  the  rapid  recognition  of  this  condition  is  the  fact  of 
.the  quick  relief  which  is  afforded  by  the  use  of  a  warm  enema  and 
the  absence  of  other  symptoms  than  colic. 

By  far  the  chief  seat  of  conditions  which  result  in  attacks  of  in- 
testinal colic  is  the  stomach,  and  failure  of  perfect  digestion  in  that 
organ  is  almost  certain  to  be  followed  by  colic.  Intestinal  parasites 
are  a  less  frequent  cause,  as  is  also  loss  of  tone  of  the  muscular  walls 
of  the  intestines. 

The  abdomen  is  generally  much  distended  with  gas,  and  if  there 
is  an  absence  of  this  feature  the  search  for  the  cause  should  be  most 
thorough,  and  it  ought  not  to  be  accepted  as  a  simple  intestinal  colic 
until  every  other  possible  cause  is  excluded.  It  is  characteristic  of 
the  condition  that  after  the  subsidence  of  the  attack  there  is  an  en- 
tire absence  of  all  ill  effects. 

Intestinal  colic  is  most  frequent  during  the  first  six  months  of 
life,  and  irrespective  of  the  fact  as  to  whether  the  infant  is  breast- 


THE    SURGICAL   SIGNIFICANCE   OF   PAIN 


33 


fed  or  bottle-fed.  Perhaps  it  would  be  no  exaggeration  to  say  that 
fully  three-quarters  of  all  the  cases  are  due  to  the  proteid  element 
in  the  food. 

In  the  diagnosis  of  the  condition  one  must  be  certain  that  the 
attacks  are  acute,  for  a  chronic  state  of  flatulence  in  an  infant  may 
be  associated  with  more  or  less  wasting  and  slight  fever,  and  would 
suggest  the  probability  of  a  beginning  tuberculous  peritonitis.  If 
there  are  elevation  of  the  evening  temperature  and  a  well-defined 
tenderness  of  the  abdomen, 
with  various  points  at 
which  there  is  evident 
thickening,  then  the  diag- 
nosis of  tuberculous  peri- 
tonitis is  almost  certain. 

It  is  in  older  children, 
in  those  beyond  infancy, 
that  abdominal  pain  is 
most  common  and  perplex- 
ing, and  we  might  well  ask 
what  is  to  be  our  attitude 
toward  this  class  of  cases ; 
what  shall  we  do  with 
them  ?  We  might  be  justi- 
fied in  making  a  somewhat 
arbitrary  division  into  the 
acute,  the  chronic,  and  the 
borderline  cases,  for  this  is 
practically  what  we  do 
when  we  approach  a  case 
for  the  first  time.  We  may  now  disregard  those  instances  in  which 
this  symptom  is  due  to  violence,  for  the  etiology  in  such  cases  is  so 
evident. 

APPENDICITIS. — Under  the  acute  cases  we  naturally  think  of 
appendicitis  first.  And  why  ?  Certainly  it  is  not  because  abdominal 
pain  is  necessarily  an  early  or  characteristic  symptom  in  appendicitis 
in  children,  for  that  is  not  so.  But  the  subject  of  appendicitis  is  so 


FIG.  16. — GENERAL  ABDOMINAL   PAIN. 

Usually  restricted  to  the  area  indicated  but  may  extend 

well  up  over  the  lower  portion  of  the  chest. 


34  PAIN 

constantly  forced  upon  our  attention  that  we  are  often  led  to  give  it 
undue  prominence  in  our  efforts  to  make  a  diagnosis. 

Why  not  give  a  similar  consideration  to  those  conditions  which 
are  much  less  common  than  appendicitis,  but  which  are  just  as  im- 
portant of  recognition,  if  any  adequate  treatment  is  to  be  instituted  ? 
The  recognition  of  appendicitis  is  made  so  comparatively  easy  that 
it  is  often  diagnosed  when  it  does  not  really  exist.  On  the  other 
hand,  there  are  borderline  cases  that,  on  account  of  their  indefinite 
symptomatology  and  the  absence  of  a  clean-cut,  well-defined  clinical 
picture,  are  not  adequately  treated,  the  mild  chronicity  of  the  symp- 
toms or  their  appearance  at  long  intervals  not  being  sufficient  to 
emphasize  the  real  seriousness  of  the  condition  until  it  is  too  late. 
These  cases  are  usually  classed  under  the  popular  lay,  but  unscien- 
tific, misnomer,  "bilious  attacks." 

Appendicitis  exhibits  three  cardinal  symptoms :  localized  ab- 
dominal pain,  localized  abdominal  tenderness,  and  rigidity  of  the 
right  recti  muscles. 

Of  these  three  the  first  is  the  least  important  in  diagnosis,  for 
it  may  be  slight.  Usually,  however,  pain  is  severe  and  intermittent, 
so  that  the  child  complains  as  of  colic.  The  child  (unless  of  much 
intelligence  and  over  six  or  seven  years  of  age)  exhibits  its  usual 
inability  to  definitely  locate  the  pain,  and  in  most  instances  when  it 
is  somewhat  definitely  located  it  is  referred  to  the  umbilicus. 

Tenderness  is  a  much  more  constant  feature,  and  is  seldom,  if 
ever,  absent.  By  palpation  it  is  located  in  the  right  inguinal  region, 
but  the  whole  abdomen  may  be  hyperesthetic.  Even  in  this  case 
there  is  more  acute  tenderness  in  the  right  inguinal  region. 

Muscular  rigidity  is  the  last  mentioned  and  yet  the  most  valu- 
able sign  of  the  three,  for  it  is  never  wanting  in  some  degree.  It  is 
particularly  marked  in  the  lower  quadrant  on  the  right  side,  but 
unless  the  child  is  unusually  quiet  it  is  most  difficult  to  demonstrate. 

Rise  of  temperature  may  be  absent  or  moderate,  or  there  may 
be  considerable  pyrexia,  the  usual  ranges  being  between  100°  and 
104°  F.  It  must  be  remembered,  however,  that  the  height  of  the 
fever  is  no  indication  of  the  severity  of  the  disease.  Associated  with 
the  fever  there  is  generally  more  or  less  vomiting,  which  is  usually 


THE   SURGICAL   SIGNIFICANCE   OF   PAIN  35 

repeated,  and  may  persist  until  it  becomes  first  bilious,  then  fecal 
(the  latter  being  very  rare). 

In  contrast  to  the  usually  low  temperature  the  pulse  is  charac- 
teristically rapid  and  is  thin  and  thready.  Thirst,  which  is  marked, 
and  constipation,  which  is  obstinate,  are  the  rule,  although  the  at- 
tack may  at  times  be  preceded  by  diarrhea.  The  child  often  as- 
sumes a  dorsal  position  with  the  right  limb  flexed  at  the  hip  and 
knee.  The  termination  of  the  disease  is  by  resolution,  the  develop- 
ment of  general  peritonitis,  or  the  formation  of  an  abscess. 

An  attack  of  appendicitis  is  usually  sudden,  and  the  acute  catar- 
rhal  type  may  subside  within  forty-eight  hours  and  fail  to  be  recog- 
nized. However,  if  all  cases  of  supposed  acute  attacks  of  indiges- 
tion were  examined  after  a  subsidence  of  all  symptoms,  in  many 
instances  a  careful  palpation  would  reveal  a  slight  thickening  and 
induration  about  the  region  of  the  appendix,  and  the  true  nature 
of  the  attacks  would  thus  be  discovered. 

It  is  not  unusual  for  several  such  attacks  to  occur  within  a  few 
months  or  years,  and  in  every  instance  be  attributed  to  some  error 
in  diet.  The  value  in  recognizing  such  attacks  is  in  advising  ap- 
propriate measures  for  the  prevention  of  a  severe  suppurative  form 
of  the  disease,  which  is  liable  to  appear  at  any  time,  either  during 
the  course  of  one  of  j:he  mild  attacks  or  directly  after  it. 

If  an  abscess  is  formed  then  this  is  recognized  by  the  boggy  feel 
of  the  tumor  and  exploration  by  the  fingers  through  the  rectum. 

Symptoms  which  are  strongly  suggestive  of  an  abscess  are  fluc- 
tuating fever  (with  the  history  of  chills  in  older  children  or  con- 
vulsions in  infants),  a  persistently  coated  and  furred  tongue,  and 
increasing  prostration. 

The  value  of  a  blood  count  is  doubtful  in  children.  ,  Such  a 
count  requires  the  most  careful  technique,  and  to  avoid  error  there 
must  be  several  counts  daily,  and  if  the  pus  becomes  encysted  the 
count  is  of  lessened  value.  For  practical  general  work  it  is  useless. 

When  an  abscess  has  developed  the  course  of  such  is  very  in- 
definite, sometimes  persisting  with  symptoms  of  a  mild  septicemia 
for  weeks.  It  is  very  rare  that  severe  symptoms  are  persistent  for 
a  considerable  period.  Peritonitis  sometimes  will  develop  upon  the 


36  PAIN 

third  or  fourth  day,  and  usually  collapse  and  death  quickly  follow 
in  such  cases. 

The  symptoms  which  are  the  most  suggestive  of  such  an  ex- 
tension are  an  otherwise  unexplained  rise  in  the  temperature,  ab- 
dominal distention,  rather  sudden  subsidence  of  the  localized  pain, 
to  be  followed  shortly  by  generalized  abdominal  pain,  tympanites, 
and  collapse. 

The  diagnosis  must  be  made  first  from  acute  indigestion,  which 
usually  exhibits  a  higher  temperature  and  much  more  rapid  sub- 
sidence of  the  acute  symptoms,  and  which  exhibits  no  thickening  in 
the  region  of  the  appendix  when  palpation  is  later  practiced.  Late 
palpation  should  always  be  performed. 

From  volvulus  and  intussusception  the  diagnosis  is  usually  read- 
ily made,  for  in  these  conditions  there  is  absence  of  the  temperature 
rise,  and  there  is  present  the  passage  of  bloody  stools  or  mucus  dis- 
charges from  the  rectum  which  are  accompanied  with  tenesmus  and 
the  development  of  a  left-sided  tumor,  as  a  rule.  The  tympanites 
may  be  so  early  in  appearance  and  so  marked  in  degree  that  the 
tumor  cannot  be  made  out. 

Nephritic  colic  may  simulate  appendicitis  for  a  time,  br.t  the 
pain  is  limited  to  the  lumbar  region,  and  instead  of  increasing  is 
decreased  by  pressure.  The  pain  generally  radiates  along  the  course 
of  the  ureter  and  is  relieved  to  an  extent  by  urination.  There  is  no 
muscular  rigidity  of  the  abdomen.  Slight  fever  may  be  present,  but 
this  is  unusual. 

Hepatic  colic  sometimes  has  a  most  acute  onset,  with  severe  pain 
and  vomiting,  and  may  simulate  appendicitis,  but  the  pain  is  more 
severe  and  persistent  in  character  and  confined  mostly  to  the  lower 
portion  of  the  right  side  of  the  chest.  Typhoid  fever  is  sometimes 
hard  to  differentiate,  particularly  when  the  history  is  vague  and  the 
symptoms  are  not  pronounced.  It  is  then  necessary  to  delay  judg- 
ment or  apply  the  Widal  test. 

Pneumonia  of  the  lower  lobe  may  have  an  onset  much  like  ap- 
pendicitis, and  with  a  similar  abdominal  pain,  which  is  due  to  in- 
volvement of  the  lower  dorsal  nerves,  so  that  it  is  necessary  to 
carefully  examine  the  chest  to  distinguish  the  real  disease.  The 


THE    SURGICAL   SIGNIFICANCE   OF   PA  IX  37 

symptoms  which  would  suggest  a  lung  condition  are :  sudden  rise  of 
temperature  to  103°  F.  or  over,  and  its  maintenance  above  that 
point,  increased  respirations  (out  of  proportion  to  pulse),  relaxed 
abdominal  muscles,  and  cough. 

ACUTE  PERITONITIS  is  usually  easy  to  recognize  011  account  of 
the  well-defined  symptoms,  chief  of  which  is  severe  and  diffused 
abdominal  pain.  This  pain  is  increased  by  the  slightest  degree  of 
pressure,  so  that  the  motion  of  the  child,  coughing,  sneezing,  or  jar- 
ring the  bed  will  increase  the  suffering  greatly.  The  result  is  that 
the  child  remains  immobile  upon  the  back,  with  the  legs  drawn  up  to 
relieve  the  tension  on  the  abdominal  muscles. 

The  onset  is  nearly  always  quite  abrupt,  with  vomiting  and  rise 
of  temperature,  the  vomiting  being  usually  present  only  at  the  onset 
and  the  temperature  reaching  103°  or  105°  F.  The  most  constant 
feature  of  the  disease  is  the  swollen  and  tympanitic  abdomen.  The 
distention  is  diffuse  in  nearly  every  instance,  but  rarely  it  may  not 
be  so  regular.  Constipation  is  the  rule. 

Outside  of  the  local  symptoms  there  is  evidence,  from  the  gen- 
eral ones,  of  the  seriousness  of  the  disease.  From  the  start  pros- 
tration is  marked  and  the  pulse  is  weak  and  small.  The  pain  is 
evidenced  by  the  drawn  and  pinched  features,  and  the  extremities 
are  in  some  cases  cold  and  clammy.  The  mind  is  generally  clear. 
When  the  vomiting  persists  it  is  usually  an  indication  that  collapse 
will  quickly  supervene. 

In  childhood  the  course  of  the  disease  is  usually  rapid  (three 
or  four  days),  but,  if  of  a  moderate  severity,  the  course  may  be  ten 
days,  and  after  that  time  there  is  generally  a  localization  of  the 
process  with  good  chances  for  recovery.  If  peritoneal  abscess  de- 
velops, then  we  have  the  added  symptoms  of  hectic  temperature, 
chills,  sweating,  and  local  signs  of  tumor. 

In  young  infants  the  disease  is  not  so  well  defined,  and  therefore 
is  harder  to  distinguish.  In  them  it  usually  proves  fatal  within  the 
first  seventy-two  hours,  and  with  symptoms  so  obscure  that  often 
the  diagnosis  is  not  made.  The  pain  is  evidenced  by  the  restless- 
ness, the  constant  crying,  and  fretfulness.  In  most  cases  the  diag- 
nosis is  not  made  unless  there  has  been  a  clear  history  of  some  eti- 


38  PAIN 

ologic  factor.  In  the  newly-born  this  might  be  by  direct  infection 
through  the  umbilical  vessels ;  in  older  infants  by  traumatism,  severe 
burns,  or  as  a  secondary  condition  to  appendicitis,  hepatic  abscess, 
acute  intestinal  obstruction,  pleuritis,  gonorrheal  vulvovaginitis, 
pneumonia,  or  scarlet  fever. 

LOBAR  PNEUMONIA  is  a  very  common  cause  of  acute  abdominal 
pain  in  children,  and  one  that  is  readily  overlooked.  It  is  a  safe 
guide  that  no  matter  what  the  acuteness  of  the  abdominal  pain,  or 
even  its  location,  if  there  is  a  marked  disproportion  between  the  pulse 
and  the  respirations,  that  pneumonia  should  at  once  be  suspected  as 
its  cause.  It  has  been  our  rather  common  experience  to  have  chil- 
dren sent  to  our  hospital  ^services  for  operation  for  appendicitis,  and 
upon  examination  to  find  that  the  appendix  was  apparently  normal, 
but  that  the  pain  in  the  abdomen  was  entirely  dependent  upon  a 
right-sided  lobar  pneumonia.  So  frequently  has  this  occurred  that 
it  should  be  prominent  in  the  mind  of  every  surgeon  who  deals  with 
children. 

CATARRH  OF  THE  J.ARGE  INTESTINE  is  accompanied  by  frequent 
colicky  pains  which  are  associated  with  tenesmus  and  stools  that 
are  composed  mostly  of  mucus.  It  must  be  differentiated  from  in- 
tussusception. 

INTUSSUSCEPTION  exhibits  a  most  intense  abdominal  pain,  and 
the  onset  is  sudden,  with  repeated,  violent  vomiting.  While  the  pain 
may  be  apparently  paroxysmal,  yet  by  careful  examination  we  find 
it  to  be  continuous  with  distinct  paroxysmal  increases  and  accom- 
panied by  much  straining  and  screaming.  Prostration  is  always 
extreme.  At  first  there  is  usually  the  passage  of  small  quantities  of 
blood  and  mucus,  or  at  times  these  may  be  passed  with  small  quan- 
tities of  feces.  Other  cases  show  an  entire  absence  of  any  discharge 
from  the  rectum  from  the  beginning. 

The  most  characteristic  feature  is  the  formation  of  a  smooth, 
slightly  movable,  very  tender,  cylindrical  tumor,  palpable  through 
the  abdominal  wall  and  usually  felt  above  the  umbilicus,  extending 
toward  the  right  flank. 

INTESTINAL,  PARASITES  may  be  suspected  as  the  cause  of  colic  if 
the  pain  occurs  in  the  day  upon  an  empty  stomach,  but  the  only 


THE   SUKGICAL   SIGNIFICANCE   OF   PAIN  39 

positive  diagnosis  is  made  by  their  removal  resulting  in  an  entire 
subsidence  of  all  the  symptoms. 

The  pain  in  SPINAL  CARIES  is  usually  worse  at  night,  and  is  re- 
ferred to  those  parts  of  the  abdomen  which  are  the  site  of  the  dis- 
tribution of  the  nerves  that  are  nearest  the  site  of  the  spinal  lesion. 

In  NEPHRITIC  COLIC  there  is  usually  a  distinct  family  history 
or  history  of  previous  attacks,  and  it  follows  exercise  as  a  rule. 

STRANGULATED  HERNIA  is  not  difficult  of  detection,  for  the  local 
signs  are  usually  well  marked,  leaving  little  chance  of  error.  The 
pain  is  similar  to  that  of  other  intestinal  obstructive  conditions. 

OVERDISTENDED  BLADDER  may  occur  during  the  course  of  sev- 
eral diseases  and  be  directly  the  cause  of  most  severe  abdominal  pain, 
and  it  must  be  taken  into  account  as  a  possible  cause  of  acute  ab- 
dominal pain  and  differentiated. 

LEAD  COLIC  would  hardly  be  considered  as  a  cause  of  abdominal 
pain,  and  yet  we  have  observed  an  instance  in  which  it  was  the  only 
reasonable  cause,  and  removal'  of  the  susceptible  child  from  the 
home  that  was  being  decorated  resulted  in  immediate  relief. 

ACUTE  RHEUMATIC  FEVER  may  have  as  its  first  and  chief  mani- 
festation painful  involvement  of  the  abdominal  musculature.  One 
of  us  has  reported  several  such  cases.*  In  differentiation  the  sur- 
geon must  consider  the  two  types  of  influenza  which  are  commonly 
associated  with  abdominal  pain — the  gastroenteric  and  the  nervous 
types. 

ACUTE  GASTRIC  DILATATION,  which  is  not  as  rare  as  supposed, 
but  which  is  often  overlooked,  may  cause  great  abdominal  pain.  In 
the  stomach  tube  we  have  a  perfect  means  of  diagnosis,  and  if  it  was 
more  often  applied  as  a  diagnostic  and  therapeutic  measure  under 
the  circumstances  of  the  two  chief  etiological  factors — operation  and 
infections  in  general — fewer  cases  would  be  overlooked, 

MOVABLE  KIDNEY  is  another  condition  that  is  supposed  to  be 
rare  in  childhood,  and  yet  when  looked  for  is  frequently  found  to 
exist.  It  may  be  the  cause  of  most  misleading  pain,  and  when  right- 
sided  has  been  known  by  us  to  be  mistaken  for  appendicitis. 


*  Am.  J.  of  Obstets.,  1911. 


40  PAIN" 

CHRONIC  GASTRIC  DILATATION  is  commonly  a  cause  of  long-con- 
tinued abdominal  pain  in  children,  and  is  apt  to  be  mistaken  for  the 
chronic  indigestion  with  which  it  is  so  commonly  associated.  The 
stomach  tube  is  the  best  means  that  we  have  of  clearing  up  the  diag- 
nosis. 

CASSATION  OF  THE  MESENTERIC  GLANDS  causes  chronic  abdom- 
inal pain  with  acute  exacerbations,  which  are  frequent,  but  the  as- 
sociated symptoms  should  make  detection  easy,  although  repeated 
examinations  may  have  to  be  made  before  any  glands  can  be  palpated. 

Headache. — Until  the  child  reaches  the  age  of  five  years  it  is  not 
always  easy  to  distinguish  headache,  although  the  two  conditions 
under  which  it  occurs  in  childhood  which  are  of  interest  to  the 
surgeon  are  those  in  which  the  pain  is  of  such  a  character  and  in- 
tensity that  it  can  hardly  be  overlooked  even  in  the  youngest  child. 
These  conditions  are  intracranial  tumor  and  meningitis. 

In  fact,  headache  in  children  under  the  age  of  five  is  unusual 
except  as  it  occurs  in  connection  with  disease  or  injury  of  the  brain 
or  its  meninges.  Occurring  in  children,  its  significance  is  much 
more  than  in  adult  life,  and  it  must  therefore  be  considered  as  an 
important  symptom  needing  a  definite  explanation. 

In  the  presence  of  an  acute  headache  with  fever  the  first  consid- 
eration is  to  determine  whether  or  not  the  headache  is  due  to  the  rise 
of  temperature,  and  therefore  we  must  decide  it  by  the  intensity  of 
the  fever  and  the  character  of  the  headache. 

In  regard  to  the  former,  headache  is  rare  with  the  temperature 
under  103°  F.,  unless  brain  or  meningeal  disease  or  injury  are  pres- 
ent. In  regard  to  the  character  of  the  headache,  when  due  to  a  rise 
in  temperature,  it  is  relieved  by  pressure  over  the  temples,  by  cold 
applications,  and  massage  of  the  veins  of  the  neck,  but  is  increased 
by  active  motion. 

The  headache  of  tuberculous  meningitis  is  usually  very  severe 
and  continuous,  bearing  absolutely  no  relation  to  the  temperature, 
which  may  be  low.  Generally  speaking,  the  more  disproportion 
there  is  between  the  intensity  of  a  fever  and  the  intensity  of  the 
headache  the  greater  the  probability  of  meningeal  or  cerebral  dis- 
ease. 


THE    SURGICAL   SIGNIFICANCE   OF   PAIN 


41 


The  headache  of  purulent  meningitis,  of  simple  meningitis,  and 
of  the  epidemic  form  of  cerebrospinal  meningitis  occurs  early  during 
the  onset  and  is  usually  intense.  Not  uncommonly  it.  is  the  one  symp- 
tom that  overshadows  all  the  others  for  a  time. 

Because  of  the  circumstances  preceding  its  occurrence,  an  acute 
intense  headache  in  children  does  not  usually  mislead  the  surgeon 
for  any  length  of  time.  Following  certain  injuries  or  operative 
procedures,  or  when  injury  is  added  to  or  associated  with  certain 

Anemia 

Epilepsy 

Meningitis 


Anemia 

Autointoxication 

Eye-strain 

Syphilitic  nodes 

Disease  and  foreign 

bodies  in  the 

nasopharynx 


f  Caries  of  the  teeth - 
Otitis  media 
Foreign  body 


Meningitis 
Epilepsy 
Spinal  caries  of 
cervical  region 
Middle-ear  disease 


FIG.  17. — DIAGNOSTIC  SIGNIFICANCE  OP 
HEADACHE  IN  CHILDREN. 


diseases,  the  occurrence  of  inflammatory  conditions  of  the  brain  or 
its  coverings  is  often  looked  upon  as  a  possibility,  and  thei'efore  the 
occurrence  of  this  one  symptom  is  not  apt  to  be  misinterpreted  if  it 
persist  for  any  time. 

Most  of  the  surgeon's  consideration  of  headache  will  be  given 
to  those  of  a  chronic  nature.  And  chronic,  persistent  headache  in 
children  should  always  excite  the  suspicion  of  possible  tumor  of  the 
brain.  It  is  by  far  the  most  prominent  feature,  being  persistent  and 
severe,  but  not  so  intense  as  in  adults.  It  often  shows  its  greatest 


42  PAIN 

intensity  during  the  night  or  in  the  early  morning.  It  is  most 
severe  when  the  tumor  is  in  the  posterior  cranial  fossa.  Closely  as- 
sociated with  the  headache  are  vertigo  and  vomiting  and  optic  neu- 
ritis, so  that  the  association  of  such  symptoms  would  at  once  exclude 
most  other  conditions.  Only  one  thing  seems  to  affect  the  severity 
and  persistency  of  the  headache,  and  that  is  the  occurrence  of  hydro- 
cephalus,  for  when  this  develops  the  pain  may  entirely  disappear. 

Only  a  complete  examination  will  satisfactorily  exclude  the 
chronic  headaches  which  are  due  to  disease  of  the  organs  of  special 
sense,  and  in  all  instances  of  chronic  headache,  particularly  those 
which  show  more  or  less  tendency  to  exacerbation,  possible  local 
causes  in  these  organs  should  be  sought. 

In  the  ears  there  may  be  an  impacted  body  or  the  existence  of  a 
chronic  otitis. 

The  eyes  may  be  the  site  of  muscular  weaknesses,  strabismus, 
errors  of  refraction,  keratitis  or  iritis,  and  these  will  in  time  be  the 
cause  of  more  or  less  persistent  headache. 

In  the  nasal  passages  there  may  be  an  impacted  body  (young 
children  are  so  fond  of  placing  foreign  bodies  in  the  nostrils  and  the 
ears)  polypi,  hypertrophic  rhinitis,  or  adenoid  vegetations  which  are 
the  cause. 

Migraine  is  too  paroxysmal  in  its  occurrence  to  cause  any  con- 
fusion with  the  chronic  headaches  due  to  brain  injury  or  disease. 

Earache. — Pain  in  the  ear  is  most  characteristically  present  in 
tWo  conditions  that  may  have  a  surgical  aspect,  otitis  and  mastoid- 
itis.  Acute  otitis  is  usually  secondary  to  some  infective  process  in 
the  nasopharynx,  with  extension  through  the  Eustachian  tube.  Pain 
in  such  instances  is  a  more  or  less  prominent  feature  associated  with 
moderate  fever.  In  infants  otitis  is  not  readily  diagnosed,  and  com- 
monly the  problem  presented  by  the  symptomatology  is  the  detection 
of  the  cause  of  an  indefinite  and  persistent  elevation  of  the  tem- 
perature with  restlessness.  The  absence  of  definite  otoscopic  signs 
is  the  rule  rather  than  the  exception,  although  the  pain  which  can- 
not be  definitely  located  by  so  young  a  patient  is  the  cause  of  the 
restlessness. 

In  older  children  the  pain  is  located  more  definitely,  and  is  usu- 


THE    SURGICAL   SIGNIFICANCE   OF   PAIN 


43 


ally  early  and  severe.  It  must  be  recalled,  however,  that  every  far- 
ache  does  not  mean  otitis,  for  sometimes  the  pain  is  reflex  from  dental 
caries,  etc.  In  every  case  of  doubtful  origin  a  careful  examination 
of  the  ear  is  absolutely  essential.  Mastoiditis  may  be  primary  or 
secondary.  Primary  mastoiditis  is  a  slow  and  usually  painless 
process,  without  much  fever,  but  with  extensive  bone  destruction 
and  no  intracranial  symptoms  of  any  extent.  There  is  no  historv 
of  otitis,  and  the  membrane  is  normal. 

Secondary  mastoiditis  usually  occurs  in  from  two  to  eight  weeks 
after  tympanic  suppuration, 
and  usually  with  an  acute  on- 
set. The  signs  of  mastoiditis 
are  increase  in  the  temperature, 
cessation  of  otorrhea,  edema  or 
swelling  back  of  the  auricle, 
with  heat,  redness  and  pain,  and 
constitutional  symptoms  due  to 
the  local  inflammation.  In 
some  instances  pus  may  con- 
tinue to  ooze  through  the  open- 
ing in  the  membrane,  or  occa- 
sionally there  may  be  increased 
discharge  with  lessened  pain, 
although  the  other  symptoms  be- 
come exaggerated.  While  it  is 
in  some  instances  a  difficult 
matter  to  demonstrate  a  slight  mastoid  tenderness,  persistent  tender- 
ness over  one  side  should  always  arouse  suspicion.  The  point  of 
greatest  tenderness  is  close  behind  the  auricle  just  over  the  antrum, 
and  tenderness  in  this  area,  particularly  if  associated  with  a  cessation 
or  diminution  in  the  discharge  which  has  occurred  rapidly,  should 
always  be  regarded  as  significant.  The  characteristic  otoscopic  ap- 
pearances are  bulging  of  Shrapnell's  membrane  and  drooping  of  the 
upper  posterior  wall  of  the  external  meatus  (Bacon). 

Several  complications  and  sequelae  may  follow  otitis  or  mastoid- 
itis, the  chief  of  which  are  meningitis,  which  frequently  results  in 


FIG.  18. — MASTOID  ABSCESS,  SHOWING  THE 
CHARACTERISTIC  SWELLING  BEHIND  THE 
EAR  AND  PUSHING  THE  AURICLE  FOR- 
WARD. 


44 

death,  cerebral  abscess  which,  if  it  occurs,  is  usually  situated  in  the 
temperospheuoidal  lobe,  thrombosis  of  the  lateral  sinus,  which  may 
be  simple  or  septic,  and  facial  paralysis  due  to  extension  of  the  in- 
flammatory process  to  the  seventh  nerve. 

Painful  Defecation.— Painful  defecation  is  usually  associated  with 
rectal  tenesmus,  but  must  not  be  confused  with  the  latter.  The  com- 
monest cause  of  painful  defecation  in  children  is  anal  fissure,  and 
this  may  require  surgical  treatment.  It  is  of  common  occurrence 
and  arises  from  several  causes,  and  the  fear  of  pain  which  accom- 
panies an  evacuation  brings  about  a  chronic  constipation  which  may 
for  a  long  time  be  the  chief  symptom.  The  pain  is  very  severe  at 
the  time  of  defecation;  and  persists  for  a  considerable  period  after 
the  evacuation. 

Hemorrhoids  may  be  the  cause  of  painful  defecation,  but  hem- 
orrhoids are  very  rare  in  children,  and  when  present  are  usually 
very  small  and  externally  located  so  that  their  detection  is  simple. 

Proctitis  is  a  cause  of  very  painful  defecation,  but  this  is  in  most 
instances  overshadowed  by  the  extreme  rectal  tenesmus  which  is  a 
prominent  part  of  this  disease. 

Rectal  tenesmus  is  differentiated  from  painful  defecation  in  that 
rectal  tenesmus  is  evidenced  by  a  constant  desire  to  empty  the  rec- 
tum, and  while  this  is  associated  with  more  or  less  pain,  the  effort 
to  defecate  is  partly  or  wholly  ineffective.  Rectal  tenesmus  with 
hemorrhages  of  any  considerable  degree  would  suggest  ulcerative 
proctitis  or  rectal  polypi. 

Painful  Urination. — Painful  urination  is  closely  associated  with 
retention  of  urine,  and  in  some  particulars  it  is  quite  impossible  to 
clinically  separate  the  two.  When  there  is  painful  urination  in  a 
child  there  is  almost  invariably  retention  also,  which  is  enforced. 

This  symptom  always  points  to  a  local  cause,  and  the  most  fre- 
quent are  as  follows : 

In  the  newly-born  it  may  be  due  to  sandy  excretions  which  per- 
sist for  a  week  or  two  (rarely  longer),  or  to  an  adherent  prepuce 
which  offers  a  mechanical  and  reflex  resistance  to  the  free  passage  of 
the  urine.  Overacidity  and  a  too  concentrated  urine  also  cause 
painful  urination  in  the  young. 


THE   SUKGICAL   SIGNIFICANCE   OF   PAIN  45 

Dysuria  is  most  severe  and  persistent,  however,  in  vesical  cal- 
culus, which  may  be  surgical  in  itself  or  its  complications. 

Calculi  may  be  formed  in  the  kidney,  and  when  not  too  large 
may  be  passed  into  the  bladder.  They  may  be  single  or  multiple, 
rounded  or  irregular  in  shape.  That  there  is  a  hereditary  tendency 
has  been  demonstrated. 

The  symptoms  are  similar  to  those  of  adult  life,  and  the  only 
positive  means  of  diagnosis  is  by  the  use  of  the  sound,  the  X-ray, 
or  the  cystoscope.  When  the  stone  is  in  the  ureter  there  is  usually 
marked  paroxysmal  pain  beginning  in  the  lumbar  region  and  radi- 
ating toward  the  pubis,  and  this  may  suddenly  cease  when  the 
passage  is  accomplished. 

In  place  of  these  symptoms  there  may  be  a  dull,  persistent  pain 
in  the  loins,  radiating  to  various  parts  of  the  lower  abdomen  and 
thighs,  and  especially  noticeable  after  exercise.  With  this  there  are 
alternating  but  irregular  scantiness  and  excess  of  urine,  some  nausea 
and  perhaps  vomiting. 

In  all  instances  of  suspected  calculi  the  possibility  of  the  symp- 
toms being  dependent  upon  cystitis  must  be  remembered  and  con- 
sidered, so  that  the  examination  must  be  planned  with  this  differ- 
entiation in  view. 

It  is  easy  to  see  how  a  balanitis  could  result  in  marked  dysuria 
when  the  parts  are  swollen  and  edematous  and  covered  with  pus,  as 
they  sometimes  are.  When  it  is  impossible  to  withdraw  the  foreskin 
and  expose  the  glans  the  disease  is  evidenced  by  the  marginal  red- 
ness with  the  appearance  of  pus  at  the  opening. 

It  is  important  to  be  sure  that  the  pus  does  not  come  from  the 
urethra,  for  in  that  case  we  would  be  dealing  with  an  entirely  dif- 
ferent proposition.  In  such  cases  the  dorsum  of  the  prepuce  should 
be  split  up  sufficiently  to  thoroughly  expose  the  glans. 

Urethritis  and  vulvovaginitis  both  are  prolific  causes  of  dysuria, 
but  microscopical  examination  of  the  discharge  is  sufficient  to  differ- 
entiate these  and  determine  their  type. 

Erosions  of  the  glans  or  of  the  labia  frequently  excite  a  degree 
of  dysuria  which  is  out  of  all  proportion  to  the  extent  of  the  lesion. 
The  suffering  may  be  extreme  in  nervous  children. 


46  EXAMINATION  OF  THE  BLOOD 

Herpes  of  the  vulva  also  causes  marked  dysuria.     Vesical  spasm 
is  accompanied  with  frequent  urination  more  than  with  pain. 


CHAPTER  VII 

THE   EXAMINATION   OF   THE    BLOOD 
GENERAL    CONSIDERATIONS 

In  the  examination  of  the  blood  in  children  the  most  skilled 
assistance  possible  should  be  obtained  for  the  laboratory  work. 

Coupled  with  this  there  must  be  considerable  judgment  shown 
by  the  surgeon  in  his  adaptation  of  the  laboratory  findings. 

The  practice  is  far  too  common  of  accepting  the  laboratory  find- 
ings as  final  and  conclusive,  and  this  attitude  continues  to  lead  many 
into  error,  and  has  done  more  than  any  other  one  thing  to  bring 
blood  examinations  into  partial  disrepute. 

There  must  always  be  a  sane  and  reasonable  interpretation  of 
the  laboratory  findings  as  they  are  associated  with  (and  not  discon- 
nected from)  the  clinical  manifestations.  These  findings  should 
be  used  merely  as  one  of  several  aids  which  help  to  guide  the  surgeon 
to  a  correct  appreciation  of  the  clinical  manifestations.  To  be  of 
any  real  service  to  the  surgeon  the  blood  findings  must  fit  more  or 
less  accurately  with  the  other  data  of  which  he  is  already  pos- 
sessed. Or,  in  other  words,  if  the  preponderance  of  evidence  is 
given  to  the  blood  findings  in  all  cases,  and  the  clinical  manifesta- 
tions are  made  subservient  to  the  laboratory  methods  of  examination, 
constant  error  will  be  the  result.  The  surgeon  must  correlate  his 
blood  findings  with  the  clinical  evidences  in  all  instances. 

It  must  always  be  remembered  that  the  study  of  the  blood  in 
children  has  not  been  as  satisfactory  as  in  adult  life,  and  that  in  a 
way  it  is  still  in  the  experimental  stage,  for  conclusions  are  neither  as 
definite  nor  the  examination  as  free  from  possible  error  as  in  later 
life. 

In  the  further  consideration  of  the  methods  of  blood  examination 


GENERAL    CONSIDERATIONS 


we  will  disregard  the  many  details  except  in  so  far  as  they  are  of 
service  to  the  surgeon  and  are  applicable  to  children.  For  the  de- 
tails of  complete  blood  examinations  the  reader  is  referred  to  the 
many  excellent  books  upon  this  special  subject. 

Method  of  Obtaining  the  Specimen. — This  should  not  be  done  in 
the  usual  manner  with  a  sharp-pointed  needle,  but  with  some  instru- 
ment that  has  a  cutting  edge.  A  Hagedon  needle  is  always  within 
reach  of  the  surgeon,  and  is  therefore  a  serviceable  and  practical 
instrument  to  use.  If  a  large  quantity  of  blood  is  required,  an  event 


FIG.  19. — PUNCTURING  THE  LOBE  OF  THE  EAR  WITH  A  NEEDLE 
WITH  A  CUTTING  EDGE,  TO  OBTAIN  A  SPECIMEN  OF  THE 
BLOOD  WITHOUT  INJURY  TO  THE  CORPUSCLES. 


which  is  most  unusual,  then  a  hypodermic  syringe  may  be  used  to 
puncture  a  vein  after  the  part  has  been  thoroughly  prepared.  The 
constant  selection  of  one  part  (as  the  lobe  of  the  ear  or  the  finger 
tip)  is  unnecessary,  since,  in  many  instances,  it  will  serve  the  pur- 
pose better  if  the  specimen  be  drawn  from  other  parts.  The  one 
necessary  precaution  is  that  cyanosed  or  edematous  parts  be  strictly 
avoided.  The  site  of  puncture  in  children  should  be  one  in  which 
the  patient  cannot  watch  the  proceeding,  so  that  the  lobe  of  the  ear 
may  be  used.  The  objection  to  this  is  that  the  child  will  rebel  when 


48 


EXAMINATION  OF  THE  BLOOD 


it  feels  the  prick,  and  the  head  is  hard  to  control.  The  large  toe  or 
the  heel  offer  excellent  situations  for  puncture.  The  stab  must  be 
made  quickly  and  firmly  so  as  to  limit  the  amount  of  pain,  and  if 
the  stab  is  deep  enough  manipulation,  which  destroys  the  integrity  of 
the  specimen,  will  be  unnecessary. 

Before  any  such  procedure  is  undertaken  the  history  of  a  pos- 
sible hemophilia  should  be  gone  into  carefully. 

Whenever  practical  the  specimen  should  be  obtained  before   a 


FIG.  20. — TRANSFERRING  THE  BLOOD  FROM  THE  LOBE  OF  THE 
EAR  TO  THE  COVER  GLASS. 


meal,  to  avoid  possible  errors  from  the  leukocytosis  which  is  normal 
in  children  after  a  meal. 

Examination  of  the  Fresh  Specimen. — While  this  is  not  always 
practical,  it  should  be  carried  out  whenever  possible,  because  the 
advantages  of  the  stained  specimen  are  secondary  and,  all  things 
being  equal,  the  fresh  specimen  will  give  the  best  information. 

The  principle  points  which  can  be  obtained  from  the  fresh  speci- 
men are  the  study  and  detection  of  the  plasmodium  malarise,  the 
several  abnormal  changes  in  shape  and  size  of  the  blood  cells  and 
the  presence  of  excessive  numbers  of  white  cells. 


GENERAL    CONSIDERATIONS 


The  Blood  Count.- — This  is  one  feature  in  the  blood  examination 
of  children  that  should  receive  more  careful  consideration  from  the 
surgeon,  and  particularly  if  operative  procedures  are  being  consid- 
ered. It  is  in  the  detection  of  anemia  and  the  accurate  estimation 
of  its  progress  that  this  procedure  becomes  a  necessary  one  for  the 
surgeon.  The  study  of  hematology  is  quite  as  important  as  a  con- 
sideration of  the  clinical  features  in  the  anemias  of  childhood.  There- 
fore a  decrease  in  the  red  cells  would  occur  to  some  extent  in  all 
diseases  and  severe  injuries,  but  has  its  most  common  existence  in 
the  anemias. 


FIG.  21. — PLACING  THE  COVER  GLASS  WITH  THE  SPECIMEN  OF  BLOOD  UPON 

A  GLASS  SLIDE. 

The  Color  Index. — While  the  blood  count  is  of  considerable  value 
in  estimating  the  anemias,  for  the  purposes  of  diagnosis  of  anemias 
in  children  it  is  only  necessary  to  demonstrate  one  change,  and  that 
is  a  deficiency  in  the  hemoglobin.  This  may  exist  because  too  little 
is  formed  or  because  too  much  has  been  destroyed.  In  childhood  the 
blood  cells  are  unstable,  parting  with  their  hemoglobin  readily,  and 
upon  slight  provocation  exhibiting  nucleated  forms.  The  blood- 
forming  organs  are  also  worked  to  their  limit  because  of  the  demands 
of  the  growing  organism.  We  can  readily  understand  that  the 
pathology  of  the  blood  is  very  closely  associated  with  that  of  every 
individual  organ,  for  the  blood  gives  and  receives  material  from  them 


50  EXAMINATION  OF  THE  BLOOD 

all,  therefore  the  composition  of  the  blood  depends  somewhat  upon 
the  general  condition  of  all  of  the  organs  of  the  body,  and  by  a  study 
of  this  fluid  a  more  or  less  exact  index  is  given  of  the  general  con- 
dition of  the  child. 

Such  data  may  prove  of  immense  value  in  aiding  the  surgeon  to 
decide  between  immediate  and  delayed  operation,  or  in  changing 
his  usual  methods  to  suit  the  requirements  of  a  special  condition. 

It  may  be  well  to  mention  that  the  hemoglobin  percentage  in 
infants  is  comparatively  high,  and  that  while  there  is  a  rapid  fall 
during  the  first  few  days  of  life,  it  is  still  high  for  a  considerable 
period.  After  the  first  month  there  occurs  another  fall,  which  covers 
a  period  of  from  ore  to  two  months,  and  the  percentage  reached  at 
the  end  of  this  second  fall  is  the  average  for  the  first  two  years  of 
life.  The  low  limit  at  this  period  may  be  placed  at  60.  After  the 
end  of  the  second  year,  and  until  the  time  of  puberty,  there  occurs  a 
slow  but  gradual  increase,  so  that,  at  the  age  of  thirteen  or  fourteen, 
the  percentage  is  close  to  85. 


ABNORMAL    CONDITIONS    OF    THE    BLOOD 

Leukocytosis. — At  the  time  of  birth  the  leukocytes  number  12,000 
to  24,000  per  cubic  millimeter,  but  within  a  very  few  days  they 
reach  the  lower  average  of  10,000  to  15,000. 

During  the  period  between  two  years  and  puberty  the  average  is 
6,000  to  12,000. 

A  leukocytosis  may  be  physiological  or  pathological,  and  this  has 
especial  importance  during  childhood  because  physiological  leukocy- 
tosis is  exaggerated  during  the  earlier  periods  of  life.  It  is  due 
largely  to  the  concentration  of  the  blood  and  to  peripheral  stasis. 
But  irrespective  of  the  marked  physiological  leukocytosis  of  the 
newly-born,  other  factors  also  influence  the  numbers  of  leukocytes  and 
these  must  be  considered. 

Fasting  decreases  the  number  of  leukocytes  to  a  very  considerable 
degree.  This  is  true,  also,  when  the  nutrition  is  chronically  inter- 
fered with,  so  that  any  malnutrition  becomes  a  more  or  less  im- 


ABNORMAL    CONDITIONS    OF    THE    BLOOD  51 

portant  factor  to  be  taken  into  consideration  when  making  deduc- 
tions from  the  blood  examination. 

When  food  is  taken  there  is  a  rapid  increase  in  the  number,  and 
this  commonly  occurs  within  one  hour  after  the  ingestion  of  the 
meal  and  persists  for  several  hours. 

Any  active  exercise  (and  less  certainly  passive  exercises)  causes 
an  increase,  and  cool  bathing  or  sponging  will  do  the  same.  What 
has  been  called  an  agonal  leukocytosis  is  observed  in  children  shortly 
before  death  takes  place. 

Pathological  leukocytosis  occurs  in  many  of  the  conditions  of 
childhood  which  are  associated  with  disease  or  injury.  But  the 
tendency  is  to  place  too  much  importance  upon  this  method  of  ex- 
amination, which,  in  children  much  more  than  in  adults,  is  uncer- 
tain and  often  unsatisfactory. 

In  the  infections  which  are  minor  the  leukocytosis  is  of  a  mild 
grade,  while  in  moderate  infections  it  is  marked  if  the  resistance  be 
good.  In  the  very  severe  infections,  or  in  instances  in  which  the 
resistance  to  the  infection  is  low,  there  may  be  no  leukocytosis  at  all 
because  the  toxemia  is  so  intense. 

It  has  its  chief  importance  in  those  diseases  in  which  there  occurs 
pus  formation,  as  in  abscess  (except  cerebral  abscess),  peritonitis, 
osteomyelitis,  septicemia,  pyemia,  etc. 

For  instance,  following  a  pneumonia,  a  sudden  increase  in  the 
leukocytes  would  indicate  empyema,  if  the  clinical  manifestations 
suggested  such  a  possibility.  It  is  useful  also  in  differentiating  be- 
tween those  diseases  that  are  catarrhal  or  purulent,  as  for  example,  in 
a  doubtful  appendicitis.  Septic  meningitis  exhibits  a  leukocytosis; 
cerebrospinal  meningitis  shows  it  in  some  degree  in  fully  two-thirds 
of  the  cases,  and  in  tuberculous  meningitis  there  is  ordinarily  no 
leukocytosis. 

Pathological  leukocytosis  is  preceded  by  a  very  brief  period, 
during  which  there  is  decided  diminution  in  the  number  of  leu- 
kocytes, and  this  is  due  to  the  initial  shock  caused  by  the  irritant. 

It  might  be  well  to  accept  the  generally  recognized  division  of 
leukocytosis  into: 

(a)  Inflammatory  leukocytosis,  or  that  which  is  dependent  upon 


52  EXAMINATION  OF  THE  BLOOD 

inflammation  or  infection;  examples  of  which  are  abscess,  sepsis, 
pneumonia,  scarlet  fever,  etc. 

(b)  Post-hemorrhagic  leukocytosis,  or  that  which  is  evident  within 
a  few  hours  after  an  acute  hemorrhage,  and  which  persists  for  from 
three  to  five  days  (gradual  hemorrhage  does  not  seem  to  produce  it). 

(c)  Leukocytosis  of  the  malignant  growths. 

(d)  Toxic  leukocytosis,  as  is  observed  in  the  non-bacterial  poi- 
sonings, such  as  alcohol,  mercury,  ammonia,  etc.,  and  in  poisonings 
of  the  system  such  as  occur  in  uremia  and  snake-bite. 

Generally  speaking,  it  may  be  said  that  the  presence  of  a  leu- 
kocytosis is  good  evidence  that  there  is  sufficient  resistance  to  an  in- 


FIG.  22. — METHOD  OF  SPREADING  A  SPECIMEN  OF  THE  BLOOD 

UPON  A  SLIDE  FOR  A  DRY  SMEAR. 

The  blood  gathered  on  one  slide  is  gently  and  evenly  spread 
by  the  edge  of  the  other  slide. 

flammation  or  infection.  Thus,  it  may  prove  serviceable  at  times  to 
search  for  its  existence  in  any  child  who  is  the  subject  of  an  in- 
flammation of  pyogenic  genesis.  The  value  of  such  examination  is, 
however,  lessened  in  children  because  the  absence  of  a  leukocytosis 
does  not  in  them  always  mean  that  there  is  no  inflammation  or  in- 
fection. The  little  patient's  system  may  be  so  overpowered  by  the 
virulence  of  the  infection,  or  the  resistance  of  the  child  may  be  so 
low  that  leukocytosis  may  be  absent. 


ABNORMAL    CONDITIONS    OF    THE    BLOOD 


In  other  instances,  as  when  the  products  of  the  inflammation  or 
infection  are  walled  off  and  become  encysted,  no  further  absorption 
taking  place,  the  leukocytes  approximate  the  normal. 

A  progressively  increasing  leukocytosis  is  indicative  of  an  ensu- 
ing suppurative  process,  and  therefore  it  may  at  times  become  the 
indicator  for  treatment,  for  if  some  condition  be  present  that  might 
give  rise  to  pus  formation  the  progressive  leukocytosis  would  indi- 
cate that  suppuration  was  impending  and  therefore  the  wisdom  of 
undertaking  some  surgical  procedure  to  forestall  it  may  have  to  be 
considered. 


FIG.  23. — PUNCTURE  OF  A  VEIN  TO  SECURE  THE  BLOOD  FOR  EXAMINATION. 
A  towel  or  bandage  wrapped  snugly  about  the  part  makes  the  veins  more  prominent 
and  the  needle  of  the  syringe  is  so  placed  that  the  natural  course  of  the  blood  in  the 
vein  is  not  interfered  with. 

Many  of  the  infections  are  not  associated  with  a  leukocytosis, 
as,  for  instance,  typhoid  fever,  measles,  parotiditis,  intermittent 
fever,  uncomplicated  tuberculosis,  etc.  This  absence  therefore  might 
in  some  instances  have  a  diagnostic  value  in  that  it  adds  to  the  value 
of  the  deductions  made  from  other  observations.  The  value  of  a 
leukocytosis  as  a  diagnostic  and  prognostic  aid  in  surgery  depends 
not  merely  upon  the  actual  number  of  leukocytes  present,  but  more 
upon  the  maintenance  of  the  relative  proportions  of  the  polymorpho- 
nuclears  to  the  total  number  of  leukocytes. 

It  cannot,  however,  be  too  definitely  stated  that  the  value  of 


54  EXAMINATION    OF    THE    BLOOD 

leukocytosis  as  a  diagnostic  and  prognostic  aid  is  of  greatly  less  value 
during  the  period  of  childhood  than  in  later  life. 

The  subject  certainly  needs  much  more  study  and  observation 
before  the  surgeon  can  rely  with  comfortable  certainty  upon  the 
findings.  It  is  not  alone  that  the  findings  are  often  unsatisfactory 
and  inaccurate,  but  the  application  of  them  to  the  clinical  needs 
requires  much  systematic  and  careful  study. 

Leukopenia. — Leukopenia,  or  a  diminution  in  the  white  blood  cells, 
indicates  some  serious  nutritional  fault,  and  is  present  in  the  severe 
anemias  or  in  leukemia,  which  is  complicated  with  infection,  as  well 
as  being  present  in  many  of  the  minor  affections  of  childhood.  If 
infection  be  present  it  indicates  that  there  is  no  resistance  to  the 
infection.  In  any  event,  its  surgical  significance  is  that  surgical 
procedure  along  the  line  of  operative  relief  of  any  extent  is  only 
justifiable  under  the  most  urgent  circumstances. 

Eosinophilia. — An  increase  in  the  eosinophiles  is  common  to  many 
conditions  of  childhood,  but  still  in  some  instances  may  have  some 
diagnostic  or  prognostic  value.  It  is  present  more  or  less  promi- 
nently in  the  malignant  tumors,  in  the  infections  by  animal  parasites, 
purpura  and  hemorrhagic  exudate;  in  diseases  in  which  the  bone 
marrow  becomes  diseased,  in  urticaria,  phemphigus,  scarlet  fever, 
after  most  of  the  fevers,  and  frequently  in  rheumatism.  As  it  is  in- 
dicative of  an  active  degeneration  of  the  blood,  it  becomes  an  un- 
favorable prognostic  indicator,  although  in  scarlet  fever  and  chloro- 
sis its  presence  may  be  viewed  with  some  favor. 

Lymphocytosis. — The  lymphocytes  are  normally  more  numerous 
than  in  adult  life,  and  this  needs  to  be  remembered  by  the  examiner, 
for  many  instances  of  supposed  lymphocytosis  are  not  so,  but  merely 
exhibit  the  normal  condition  for  the  earlier  periods  of  life,  and  in 
this  particular  may  prove  misleading. 

Even  when  a  lymphocytosis  is  accepted  as  a  fact  there  must  !>;• 
evidences  of  both  a  relative  and  an  absolute  increase,  because,  if  the 
polynuclear  neutrophiles  are  decreased  in  number,  there  may  be  an 
apparent  but  not  an  actual  increase  in  the  lymphocytes. 

There  occurs  a  lymphocytosis  in  many  of  the  severe  types  of 
disease,  as,  for  instance,  in  gastroenteritis,  pertussis,  rachitis,  scor- 


DIAGNOSTIC  VALUE   OF  THE  X-RAY  55 

butus,  and  congenital  syphilis,  but  the  greatest  increase  occurs  in 
lymphatic  leukemia. 


CHAPTEK  VIII 

THE   DIAGNOSTIC  VALUE   OF  THE   X-RAY 

When  we  consider  fractures  the  diagnostic  value  of  the  X-ray 
can  hardly  be  overestimated  if  we  are  positive  that  the  technique  is 
perfect  and  the  operator  has  had  sufficient  experience. 

There  is  this  danger,  however,  in  X-ray  work,  that  the  results 
are  modified  to  a  large  extent  by  the  ability  of  the  operator  and  his 
equipment.  It,  however,  is  scarcely  possible  for  a  fracture  to  be 
overlooked  with  the  use  of  ordinary  care,  although  the  greatest  dif- 
ficulty will  be  experienced  in  the  detection  of  fractures  of  the  skull, 
or  the  bones  of  the  face. 

The  limitations  of  accuracy  are  due  to  the  inability  to  bring 
certain  parts  into  close  proximity  with  the  plate.  Two  exposures 
are  necessary  for  satisfactory  results,  because  a  single  picture  of  a 
fracture  in  which  the  displacement  is  in  one  plane,  and  that  the  one 
of  the  rays  as  they  fall  upon  the  plate,  may  fail  to  show  the  lesion. 
The  pictures  should  be  taken  at  right  angles  to  each  other.  Stereo- 
scopic radiographs  overcome  this. 

In  the  diagnosis  of  dislocations  the  X-ray  is  of  considerably  less 
value  than  in  fracture  because  our  other  methods  of  examination 
are  usually  satisfactory  and  quite  exact,  but  in  those  instances  in 
which  there  is  a  reasonable  doubt  as  to  the  co-existence  of  fracture 
the  X-ray  is  of  decided  value. 

In  the  diagnosis  of  bone  deformity  and  bone  disease  this  method 
of  examination  is  of  large  value  and  gives  data  which  is  of  consider- 
able value  in  the  planning  of  possible  operative  relief.  For  example, 
we  might  take  one  instance;  in  tuberculous  cavities  in  the  bones  or 
tuberculous  sequestra  in  the  articular  portions  of  the  bones,  it  is  pos- 
sible by  the  use  of  the  X-ray  to  determine  whether  or  not  the  sur- 
rounding tissues  have  been  invaded,  and  if  so,  to  what  extent,  and 


56  DIAGNOSTIC  VALUE   OF  THE   X-RAY 

therefore  it  gives  a  valuable  clew  to  the  surgeon  as  to  the  opportune 
time  for  operative  interference. 

In  the  detection  of  foreign  bodies  in  the  tissues  the  X-ray  has  a 
distinct  value,  but  two  pictures  should  be  taken  in  planes  at  right 
angles  to  each  other,  for  in  no  other  way  (except  by  stereoscopic 
radiographs)  can  the  body  be  satisfactorily  located.  This  is  so  be- 
cause the  shadow  will  not  show  the  depth. 

For  absolutely  accurate  work  one  of  the  several  localizers  may 
be  necessary,  but  in  most  instances  the  pictures  from  two  planes 
fully  answer  the  purpose  of  the  surgeon. 

Cysts,  abscesses,  aneurysms,  and  various  other  pathological  con- 
ditions are  not  always  satisfactorily  followed  in  their  course  by  the 
ordinary  clinical  methods  of  examination,  and  in  such  instances  the 
X-ray  becomes  of  considerable  aid  in  placing  a  somewhat  exact  de- 
termination of  their  progress  and  extent. 

Calculi  of  the  various  kinds  are  usually  detected  by  the  X-ray, 
but  there  may  be  some  difficulty  experienced  according  to  the  char- 
acter of  the  stone.  Most  of  the  dissatisfaction  has  come  from  un- 
avoidable imperfect  technique,  for  the  problems  of  the  radiographist 
are  most  difficult  in  this  particular  field. 

However,  the  problems  are  less  perplexing  in  children  than  in 
adults,  and  the  ease  with  which  pictures  of  the  proper  quality  may 
be  obtained  in  young  subjects  makes  this  method  of  examination 
most  satisfactory. 


SECTION  III 

ANESTHETIZA  TION 

CHAPTER  IX 

ANESTHESIA 

GENERAL    CONSIDERATIONS 

The  surgeon  must  not  expect  the  child  to  cooperate  in  the  under- 
taking of  a  surgical  procedure,  whether  it  be  an  operation,  a  pain- 
ful dressing,  painful  examination,  or  adjustment  of  injured  parts. 
Therefore  the  administration  of  an  anesthetic  is  more  frequently 
necessary  than  in  adults.  Children  bear  pain  badly,  and  therefore 
surgical  procedures  of  even  the  most  ordinary  kind  are  frequently 
cruel  unless  the  child  is  protected  by  an  anesthetic.  For  instance, 
in  the  case  of  fractures,  an  accurate  adjustment  is  often  impossible 
without  an  anesthetic,  and  in  the  matter  of  diagnosis  alone  the  com- 
bined examination  under  anesthesia  and  X-ray  is  desirable  and 
often  absolutely  necessary.  Even  in  what  are  commonly  considered 
the  minor  surgical  conditions,  we  are  convinced  that  the  shock  offered 
to  the  child  by  the  knowledge  of  what  is  taking  place  more  than 
counterbalances  the  possible  slightly  depressing  effect  of  the  primary 
stage  of  ether  anesthesia. 

Therefore  the  field  of  local  anesthesia  in  children  is  very  much 
smaller  than  in  later  life. 

Before  taking  up  the  various  anesthetics  it  is  well  to  consider 
some  points  which  apply  with  equal  force  to  all,  and  which  must 
be  worked  out  as  the  circumstances  permit. 

Preparation  of  the  Child. — It  is  not  always  possible  to  make  the 
preparation  of  the  patient  that  is  desirable,  but,  barring  those  cases 
which  come  under  the  head  of  "emergencies,"  there  should  be  a  well- 

57 


58  ANESTHESIA 

defined  course.  It  must  be  remembered  by  the  anesthetist  that  the 
same  consideration  must  be  given  to  the  age,  the  weight,  and  the 
general  condition  of  the  child  in  the  administration  of  an  anesthetic 
as  is  given  to  the  administration  of  any  powerful  drug.  Particular 
attention  must  be  paid  to  the  condition  of  the  heart,  the  lungs,  the 
kidneys,  and  the  blood.  To  avoid  repetition  the  reader  is  referred 
to  the  section  on  "Preparation  of  the  Patient"  on  page  75. 

With  this  examination  complete,  it  remains  to  clear  out  the 
child's  mouth  and  nose  just  before  the  administration  of  the  anes- 
thetic. Children  are  very  prone  to  have  foreign  bodies  in  their 
mouths,  and  it  is  surprising  to  find  how  often  our  search  reveals 
the  presence  of  candy,  chewing  gum,  buttons,  etc.  The  clearing  of 
the  mouth  and  nose  of  plugs  of  mucus  or  nasal  discharge  adds  much 
to  the  comfort  and  safety  of  administering  the  anesthetic,  besides 
helping  to  reduce  the  danger  of  post-anesthetic  pneumonia. 

The  use  of  a  weak  solution  of  cocain  with  adrenalin  has  proved 
most  satisfactory  in  diminishing  secretion  and  favoring  free  respira- 
tion. 

In  older  children  the  administration  of  a  very  small  dose  of 
morphia  and  atropin  hypodermically,  just  before  the  anesthetic, 
may  serve  in  prolonging  the  effect  of  the  latter  and  diminishing  post- 
operative pain.  However,  its  favorable  action  is  so  uncertain  that 
its  use  is  questionable,  and  in  very  young  children  it  should  not  be 

** 

given  at  all. 

The  danger  to  children  from  an  anesthetic  is  not  the  asphyxial 
element  but  the  toxic  element ;  therefore  the  conservation  of  the 
child's  normal  functioning  as  regards  its  secretions  (with  the  ex- 
ception of  the  mouth)  is  very  important.  Morphin  and  atropin  are 
both  apt  to  interfere  with  these,  and  while  all  children  are  more 
or  less  susceptible  to  the  action  of  opiates  and  unfavorably  acted 
upon  by  them,  there  are  many  who  exhibit  this  susceptibility  in 
very  marked  degree. 

The  intestinal  tract  should  always  be  freely  cleared  out  before 
the  administration  of  the  anesthetic.  If  time  permits,  some  prepara- 
tion of  castor  oil  should  be  given  and  the  food  regulated  after  that 
so  that  nothing  is  placed  in  the  digestive  tract  which  can  cause 


GENEKAL    COXSIDEBATIONS  59 

future  trouble.  When  time  does  not  permit  the  use  of  a  laxative  or 
cathartic,  a  high  rectal  enema  may  be  given  consisting  of  two  ounces 
of  sulphate  of  magnesia  (to  quickly  dissolve  the  intestinal  mucus), 
four  ounces  of  glycerin,  and  a  quart  of  warm  water.  This  is  much 
more  effectual  than  the  ordinary  and  irritating  softsoap  enema. 

The  operating  room  should  have  a  maintained  temperature  of 
from  72°  to  75°  F.  The  ventilation  of  the  room  should  be  sufficient 
to  prevent  the  usual  stuffiness  with  its  consequent  depression.  Our 
experience  has  been  that  most  operating  rooms  are  not  properly 
supplied  with  fresh  air  during  the  time  of  operation,  and  this  de- 
privation of  oxygen  markedly  influences  the  dangers  from  the  ad- 
ministration of  the  anesthetic.  There  must  be  adequate  protection  of 
the  cutaneous  surface,  therefore  as  small  a  part  as  possible  should 
be  exposed  and  the  rest  of  the  body  should  be  well  covered.  In 
infants  or  very  young  children,  or  those  who  give  any  appreciable 
evidences  of  a  low  resistant  power,  further  protection  should  be  given 
by  wrapping  unexposed  parts  in  absorbent  wool  secured  with  light 
bandages.  This  conservation  of  heat  is  very  important  in  long 
operations,  no  matter  what  the  age  or  nutritional  condition  of  the 
child. 

Children  tolerate  hunger  poorly,  therefore  it  is  necessai-y  to 
administer  some  form  of  nutriment  within  two  or  three  hours  of 
the  anesthetic.  This  should  be  of  such  a  nature  as  to  cause  no 
future  accident,  and  we  find  the  best  form  is  diluted  cream.  For 
instance,  the  top  ten  ounces  may  be  removed  from  a  quart  bottle 
of  milk  in  which  the  cream  has  risen  and  this  diluted  with  twenty 
or  thirty  ounces  of  plain  sweetened  water,  or,  in  older  children,  a 
weak  solution  of  a  cereal  water  or  coffee.  This  leaves  no  residue  in 
the  stomach  which  will  give  rise  to  difficulty  later.  Of  course,  in 
infants  a  much  weaker  strength  may  be  necessary. 

If  the  child  has  inadvertently  partaken  of  a  meal  shortly  before 
the  administration  of  the  anesthetic,  lavage  must  be  practiced. 

Conditions  to  Be  Watched  by  the  Anesthetist. — It  is  a  foolish  pol- 
rcy,  for  which  we  must  eventually  pay  the  penalty,  to  allow  an  in- 
experienced anesthetist  to  administer  the  anesthetic.  It  is  not  so 
much  a  question  of  tact  and  the  ability  to  secure  the  child's  confidence 


60 


ANESTHESIA 


that  is  necessary,  although  that  is  most  desirable,  but  the  dangers 
from  the  anesthetic  are  all  so  magnified  in  childhood  that  we  must 
be  certain  of  securing  the  best  possible  anesthetist  for  each  individual 
case.  Inaccuracies  of  administration  which  would  be  rather  trifling 
in  the  adult,  or  at  least  would  only  lead  to  annoying  delay  or  conse- 
quences, in  the  child  become  at  once  serious  and  often  very  grave 
situations. 

The  closest  attention  must  be  given  to  the  pupil  and  lid  reflexes, 


FIG.  24. — THROWING  THE  JAW  FORWARD  DURING  ANESTHESIA. 

This  manipulation  is  not  often  necessary  in  children  and  when  it  is,  it  should  not  be 
accomplished  in  the  usual  manner,  but  the  jaw  should  be  gently  but  firmly  held 
forward  rather  than  forced  forward. 


as  these  are  the  most  important  guides  to  the  depth  of  the  anesthesia. 
A  gradually  dilating  pupil  with  increased  corneal  lid  reflex  is  an  in- 
dication for  more  of  the  anesthetic.  A  dilating  pupil  with  absence 
of  the  corneal  lid  reflex  is  a  warning  to  reduce  the  anesthesia.  Dila- 
tation commonly  takes  place  when  there  is  much  handling  of  the 
tissues  and  indicates  a  certain  degree  of  shock  which  should  result 

o 

in  a  somewhat  lessened  degree  of  anesthesia. 

A    suddenly   dilating   pupil    with   increased    corneal   lid    reflex 


GENEKAL    CONS1DEKAT10NS  (51 

usually  indicates  an  impending  attack  of  vomiting.  The  same  is 
true  of  a  pin  point  pupil  with  shallow  respirations,  and  both  may  be 
met  with  an  increase  in  the  anesthetic. 

In  the  administration  of  the  anesthetics  there  must  be  provision 
for  the  constant  and  very  free  admixture  with  air.  Children  never 
tolerate  a  concentrated  anesthetic,  and  so  the  apparatus  and  gauze 
must  be  so  arranged  that  this  perfect  and  maintained  admixture 
is  possible. 

Lymphatisn  or  status  lymphaticus  introduces  an  element  of 
great  danger  into  anesthesia,  in  that  many  of  the  deaths  which  take 
place  with  more  or  less  suddenness  during  and  immediately  after 
anesthesia  are  directly  attributable  to  this  condition.  This  makes 
it  of  great  interest  to  the  surgeon. 

What  part  the  anesthetic  plays  in  this  condition  is  very  uncer- 
tain, but  clinically  we  know  that  they  bear  any  anesthetic  badly, 
although  there  are  several  instances  in  which  these  children  have 
been  subjected  to  anesthesia  on  previous  occasions  without  any 
alarming  result  and  have  finally  succumbed  to  a  later  administra- 
tion. 

We  are  convinced  that  the  administration  of  the  anesthetic  is 
only  one  of  many  factors  and  by  no  means  the  chief  one,  because 
many  of  these  children  die  without  undergoing  any  serious  injury 
or  surgical  procedure. 

To  avoid  repetition  the  reader  is  referred  to  page  155. 

Selection  of  the  Anesthetic. — This  will  depend  upon  the  physical 
examination  of  the  child  and  the  part  to  be  subjected  to  operation. 
In  short,  quick  procedures,  such  as  rapidly  breaking  up  adhesions 
about  a  joint,  the  adjustment  of  a  fracture,  etc.,  chloroform  or 
nitrous  oxid  may  be  selected.  The  objection  to  the  latter  is  its 
uncertainty  in  overcoming  muscular  spasm.  Chloroform  is  of  service 
when  the  large  amount  of  mucus  produced  by  ether  would  interfere 
with  the  operative  field.  Ether  may  be  dangerous  to  use  even  in 
the  presence  of  a  very  slight  bronchitis  (converting  such  into  pneu- 
monia) and  in  the  presence  of  marked  disease  of  the  heart  or 
kidneys,  or  tuberculosis  of  the  lung,  the  contraindications  to  its 
use  are  strong. 


ANESTHESIA 


VARIETY    OF    ANESTHETICS 


Ether. — In  England  chloroform  is  used  much  more  extensively 
than  any  other  general  anesthetic,  but  in  the  United  States  ether 
easily  holds  first  place  as  the  anesthetic  of  choice,  both  for  adults  and 
for  children.  Unless  it  interferes  with  a  strong  personal  preference 
which  is  backed  by  a  long  experience,  it  is  well  for  the  surgeon  to 
select  the  anesthetic  which,  in  the  consensus  of  opinion  of  his 
colleagues,  is  in  most  favor.  Such  a  stand  does  not  in  any  way 
vitiate  personal  thought,  which  should  be  fostered,  but  acts  as  a 

protection    to    the    oper- 
ator. 

The  disadvantages  of 
ether  as  they  apply  par- 
ticularly to  childhood  are 
its  unpleasant  odor,  its 
rather  slow  action,  its 
proneness  to  excite 
nausea  and  vomiting,  and 
its  tendency  to  produce 
such  an  irritation  of  the 
upper  respiratory  tract  as 
to  result  in  the  excitation 
FIG.  25.-GWATHNEY  ANESTHESIA  APPARATUS.  of  troublesome  COUgh  and 

This  apparatus  represents  one  of  the  best  methods  of 

producing  a  safe  and  comfortable  anesthesia  and       lllUC'h      mUCUS.         Besides 

is  of  particular  service  in  children.  ,  i  •     ,1  •     ,1         I»I«A        ? 

this  there  is  the  ability  ot 

the  vapor  to  immediately  reduce  the  temperature  in  its  immediate 
vicinity  between  25°  and  30°  F. 

These  few  facts  are  the  main  ones  that  must  be  considered  in 
the  administration  of  ether  in  children,  otherwise  the  technique 
does  not  differ  materially  from  the  administration  in  adult  cases. 
The  unpleasant  odor  cannot  be  overcome,  although  it  may  be  made 
less  objectionable  by  a  few  whiffs  of  cologne  given  just  previous  to 
the  anesthetic.  Its  slow  action  depends  in  some  measure  upon  the 
method  of  administration,  therefore  the  personal  element  (both 


VARIETY    OF    ANESTHETICS 


63 


patient  and  anesthetist)  enters  largely.  The  same  may  be  said  in 
regard  to  nausea,  vomiting,  or  cough:  they  are  reduced  to  a  mini- 
mum when  the  anesthetic  is  in  skilled  hands  and  the  preparation  of 
the  child  has  been  possible  and  sufficient.  When  we  consider  the 
comparative  immensity  of  the  surface  to  which  the  ether  penetrates 
and  recall  its  ability  to  lower  temperature,  we  have  a  strong  clew  to 
the  frequent  occurrence  of  post-anesthesia  catarrhs  in  children.  The 
avoidance  of  such  is  largely  a  matter  of  securing  a  warm  vapor  (if 
possible)  with  adequate  protection  of  the  cutaneous  surfaces. 

Chloroform. — Despite  the  fact  that  chloroform  is  often  wrongly 
used,  the  remains  of  a  previously  opened  package  being  commonly 


FIG.  26. — CONVENIENT  CONTAINER  FOR  SMALL  QUANTITIES 
OF  CHLOROFORM. 

With  the  breaking  off  of  the  ends  of  the  two  glass  tips,  the 
rate  of  administration  is  entirely  within  the  control  of 
the  anesthetist. 


saved  for  succeeding  anesthesias,  the  evidence  proves  that  it  is  an  un- 
certain agent  in  childhood.  There  is  a  very  rapid  deterioration 
which  occurs  after  the  container  is  once  opened,  so  that,  if  used,  the 
surgeon  should  be  provided  with  several  containers  holding  rather 
small  amounts,  in  order  that  the  anesthetist  may  use  one  or  more 
as  the  occasion  demands.  The  danger  from  the  toxic  element  is 
so  strong  in  children  that,  in  the  administration  of  chloroform,  the 

gauze  upon  which  it  is  cautiously  dropped  should  not  come  within 

i 

several  inches  of  the  face.  Near  to  the  gauze  the  vapor  is  always 
dense,  and  to  insure  even  reasonable  safety  there  must  occur  a  proper 


64  ANESTHESIA 

and  adequate  diminution  of  the  density  of  the  vapor  by  admixture 
with  air. 

Before  administration  the  face  must  be  smeared  with  some  pro- 
tective oil,  as  the  vapor  is  irritating  to  the  skin.  The  dangers  are 
similar  to  those  of  adult  life;  the  only  difference  is  one  of  degree, 
for  the  child  is,  in  every  particular,  vastly  more  susceptible  to  the 
toxic  effect  of  this  agent  and  succumbs  much  more  surely  and 
rapidly. 

During  the  chloroform  anesthesia  there  is  not  uncommonly  a 
period  of  pseudo-anesthesia,  which  precedes  the  true  anesthetic  state, 
and  is  evidenced  by  shallow  breathing,-  insensitive  cornea,  and  small 
pupil.  Its  occurrence  has  been  most  common  when  the  anesthetic  has 
been  given  irregularly,  or  there  has  been  no  marked  stimulus  to  the 
patient.  If  it  is  not  recognized,  there  may  be  some  embarrassment 
to  the  operator  who  commences  his  procedure  and  is  soon  handi- 
capped by  reflex  movement  or  a  depressed  heart. 

Chloroform  should  not  be  administered  without  a  small  plug  being 
placed  between  the  teeth.  Not  infrequently  there  occurs  a  spasm  of 
the  muscles  of  the  jaw  and,  while  valuable  time  is  being  lost  in 
attempting  to  overcome  this  so  as  to  introduce  a  mouth  gag,  the 
child  becomes  dangerously  depressed  from  the  retained  vapor.  The 
plug  usually  prevents  a  spasm,  but  if  it  occurs  then  the  introduction 
of  the  mouth  gag  is  simple  and  immediate. 

Delayed  chloroform  poisoning  is  very  rare  in  children,  but  when- 
ever it  occurs  it  is  almost  uniformly  fatal.  Its  onset  is  within 
forty-eight  hours  or  less  after  the  administration  of  the  anesthetic. 

The  symptoms  are  severe  and  persistent  vomiting,  delirium  al- 
ternating with  coma  or  apathy,  periods  of  unaccountable  screaming, 
a  rapid  pulse,  and  a  slight  jaundice. 

Acetone  may  be  detected  in  the  urine.  Whether  the  fatty  changes 
which  are  noticed  post  mortem  are  the  result  of  the  anesthetic  or 
have  been  present  before  its  administration  is  undetermined.  The 
treatment  is  one  of  judicious  but  efficient  stimulation  and  the  ad- 
ministration of  large  doses  of  alkalies  so  as  to  completely  overcome 
the  acidity  of  the  urine. 

Nitrous  Oxid.  — For  short  operations  or  procedures  in  children  this 


VARIETY    OF    ANESTHETICS 


65 


is  an  ideal  anesthetic.  The  disadvantage  of  the  bulk  of  the  appara- 
tus is  much  more  than  compensated  for  by  the  speedy  and  safe 
production  of  anesthesia  and  the  rapid  recovery  from  its  effects. 
The  one  disadvantage  is  the  great  uncertainty  with  which  this 
anesthetic  relaxes  muscles.  This,  however,  only  limits  its  field  in 
a  small  degree.  However,  we  must  recall  that  there  is  some  danger 
in  its  use  in  the  presence  of  any  well-defined  cardiac  disease. 

Nitrous-Oxygen-Ether. — This  combination  is  a  very  expensive  one 
to  use  for  prolonged  effects,  but  has  the  advantage  of  making  the 
primary  stage  of  anesthesia  very  brief,  diminishing  the  discomfort 


FIG.  27. — APPARATUS  AND  METHOD  USED  IN  INTUBATION  ANESTHESIA. 
One  tube  is  introduced  through  each  nostril.  Gauze  is  packed  in  the 
pharynx  (A)  to  prevent  the  aspiration  of  blood  or  mucus.  This  is 
Crile's  method  and  is  useful  in  operations  about  the  mouth.  After 
full  anesthesia  is  accomplished  in  the  usual  manner,  the  tubes  are 
introduced  and  the  anesthetist  and  inhaler  are  thus  both  removed  from 
the  field  of  operation. 

to  the  child,  and  somewhat  lessening  the  subsequent  nausea  and 
vomiting. 

Nitrous-Ether.- — If  nitrous  oxide  is  given  just  before  the  adminis- 
tration of  ether,  the  struggling  of  the  child  during  the  first  stage  of 
ether  anesthesia  is  reduced  considerably,  although  the  effect  of  the 
nitrous  oxid  is  so  transient  that,  commonly,  there  is  some  slight 
struggling  before  the  ether  has  been  given  in  sufficient  amount.  In 
the  hands  of  an  expert,  even  this  slight  struggling  may  be  overcome. 

Ethyl  Chlorid.— While  not  without  danger,  this  is  a  very  rapid 


66  POST-ANESTHETIC   CARE 

method  of  producing  a  very  brief  anesthesia  and  may  be  used  for 
short  operations  (30  to  60  seconds).  The  danger  comes  mostly  from 
the  attempt  at  prolonged  administration.  There  is  frequently  a 
decided  rigidity  of  the  jaw  muscles  under  the  anesthesia  and  this 
limits  its  usefulness  in  procedures  about  the  mouth. 

As  a  preliminary  anesthetic  to  ether,  ethyl  chlorid  holds  a 
valuable  place. 

CHAPTEK  X 

POST-ANESTHETIC  CAEE 

Just  as  soon  as  the  operative  procedure  is  completed  and  the 
dressings  applied,  the  child  must  be  thoroughly  dried,  and  if  any 
of  the  garments  are  wet  or  soiled  they  must  be  cha'nged  at  once. 
The  room  in  which  the  child  is  taken  to  recover  from  the  anesthetic 
should  have  an  easily  sustained  temperature  of  TO0  F.,  and  must  be 
so  isolated  from  the  rest  of  the  house  that  complete  quiet  and  rest 
may  be  obtained.  The  child  recovering  from  an  anesthetic  requires 
the  undivided  attention  of  the  nurse  so  that  such  accidents  as  falling 
out  of  bed,. tongue  swallowing,  disturbances  of  dressings,  etc.,  may. 
be  avoided. 

While  recovery  in  children  depends  largely  upon  the  amount  of 
anesthetic  used  and  also  the  length  of  administration,  yet  these  fac- 
tors are  not  so  important  as  in  adults.  In  children  there  is  a  per- 
sonal susceptibility  which  must  always  be  taken  into  account,  and 
more  depends  upon  the  skill  with  which  the  anesthetic  was  given 
than  upon  the  amount  or  the  time. 

It  is  the  duty  of  the  anesthetist  to  remain  with  his  patient  until 
the  child  shows  by  its  ability  to  dispose  of  its  vomitus  that  a  con- 
siderable degree  of  consciousness  has  been  regained.  After  the  child 
has  responded  to  questioning  or  has  cried  lustily,  it  is  safe  to  leave 
its  further  care  to  the  nurse.  It  is  often  advisable  to  allow  the 
mother  to  be  with  the  child  and  act  in  cooperation  with  the  nurse 
in  securing  mental  and  physical  rest. 

The  accidents  which  are  apt  to  occur  are  similar  to  those  in 


NAUSEA  AND   VOMITING  67 

adults,  except  that  the  child  is  more  susceptible  to  the  anesthetic 
and  is  less  capable  of  taking  care  of  itself  during  recovery.  This 
means  that  the  watching  must  be  more  careful  and  the  preparations 
for  emergencies  adequate. 

The  administration  of  oxygen  aids  very  much  in  the  speedy  and 
comfortable  return  of  consciousness. 

Nausea  and  Vomiting. — Vomiting  after  the  administration  of 
ether  should  be  expected.  It  occurs  suddenly,  is  usually  of  short 
duration  and  mild,  but  may  be  so  violent  as  to  quite  exhaust  the 
child. 

There  are  several  factors  which  favor  vomiting  and  these  should 
be  mentioned  so  that  they  may  be  avoided  when  possible: 

(a)  The  presence  of  a  large  amount  of  liquid  in  the  stomach, 
or  of  a  small  amount  of  solids,  at  the  beginning  of  the  administra- 
tion of  the  anesthetic. 

(b)  The  use  of  an  anesthetic  of  poor  quality  or  one  that  has 
been  exposed  for  some  time  to  atmospheric  influences. 

(c)  The  swallowing  of  considerable  quantities  of  blood,  mucus, 
or  saliva  during  the  administration  of  the  anesthetic. 

(d)  The  uneven  administration  of  the  anesthetic. 

There  is  another  element  that  we  must  remember  in  chloroform 
anesthesia;  while  the  above  factors  apply,  they  do  so  in  a  lesser 
degree  than  when  ether  is  administered,  but  the  usual  production  of 
thick  mucus  over  the  pharyngeal  wall  tends  to  excite  and  prolong 
vomiting  until  it  is  removed  by  vomiting  or  a  swab. 

However,  the  anesthetist  must  be  ever  mindful  that  there  some- 
times occurs  vomiting  which  has  no  connection  in  any  way  with 
the  administration  of  the  anesthetic,  but  which  has  a  significance 
which  is  all  its  own.  This  type  of  vomiting  is  serious  and  is  men- 
tioned in  detail  in  the  section  "Postoperative  Care"  on  page  93. 

We  have  found  that  cracked  ice  has  been  used  commonly  to 
allay  the  nausea  and  vomiting,  but  in  children  it  rather  tends  to 
increase  it,  so  that  its  use  should  be  restricted.  The  best  procedure 
is  to  allow,  within  two  hours,  frequent  sips  of  hot,  sweetened  water 
(about  one  dram  every  five  minutes)  for  an  hour  or  two  and  then 
a  full  glassful,  for  about  this  time  the  child  will  crave  it.  This  is 


68  POST-ANESTHETIC   CARE 

almost  immediately  followed  by  vomiting  and  the  subsidence  of  all 
nausea  and  vomiting.  After  this,  water  given  in  small  quantities 
and  at  frequent  intervals  will  usually  be  retained.  Vomiting  per- 
sisting for  over  six  or  eight  hours  after  the  withdrawal  of  the 
anesthetic  may  only  yield  to  lavage. 

When  the  vomiting  seems  to  be  of  real  distress  to  the  child,  we 
believe  that  the  administration  of  very  minute  doses  of  cocain 
hydrochlorid  in  hot  water  is  justified  so  that  the  child  may  secure  its 
rest. 

Persistent  vomiting  requires  the  same  vigorous  treatment  and 
management  as  are  used  in  adult  cases. 

Hematemesis. — This  is  exceedingly  rare  in  childhood  and  the 
mode  of  its  production  has  never  been  clearly  understood.  The 
prognosis  is  unfavorable  and  the  treatment  usually  ineffectual. 

Undue  Restlessness. — There  is  always  a  certain  degree  of  rest- 
lessness following  the  administration  of  an  anesthetic  in  children 
and  this  is  peculiarly  true  of  ether.  But  this  restlessness  soon  passes 
over.  Any  degree  of  undue  restlessness  which  is  prolonged  should 
be  the  cause  of  a  most  thorough  investigation  of  all  connected  with  the 
operation,  for  at  times  the  cause  will  be  found  in  some  easily  rectified 
condition  which,  if  neglected,  may  seriously  influence  the  final 
results. 

The  causes  of  restlessness,  exclusive  of  the  influence  of  the  anes- 
thetic, are  considered  on  page  97. 

Sweating. — This  should  always  be  regarded  as  significant  in 
children  to  whom  an  anesthetic  has  been  given.  It  does  not  occur  in 
children  simply  as  the  result  of  the  anesthetic,  as  we  see  sometimes 
in  vigorous  adults,  but  is  always  indicative  of  some  weakness  and 
shock  and  hemorrhage  should  be  suspected.  In  no  instance  should  it 
be  lightly  regarded. 

Thirst.  — There  is  a  well-defined  post-anesthetic  inhibitory  action 
upon  the  secretions  of  the  mouth  and  throat  which  general  anesthetics 
occasion  and  this  results  in  such  a  sense  of  dryness  that  it  often 
becomes  a  most  troublesome  feature.  Much  of  the  discomfort  is 
overcome  if  the  mouth  is  very  frequently  rinsed  out  with  a  mild 
antiseptic,  alkaline  solution,  used  cool.  If  the  giving  of  water,  as 


SORENESS    OF    THE    TOXGUE  69 

advised  on  page  95,  is  carried  out,  thirst,  as  well  as  the  nausea  and 
vomiting,  is  relieved. 

If  excessive,  the  relief  of  thirst  may  require  the  use  of  rectal 
saline  injections  or  subcutaneous  saline  infusion.  However,  in  chil- 
dren this  is  rarely  necessary. 


CHAPTEE  XI 


What  we  call  the  sequelae  of  the  anesthetic  are  those  conditions 
which  so  commonly  occur  as  the  result  not  alone  of  the  anesthetic, 
but  of  the  associated  influences  of  the  handling  necessary  to  the 
proper  performance  of  the  procedure.  They  are  not  due  to  the 
anesthetic  but  rather  to  the  circumstances  of  its  administration. 

Conjunctivitis. — This  does  not  occur  with  the  experienced  anes- 
thetist except  as  the  result  of  accident,  as  it  is  caused  by  the  ether  or 
its  vapor  coming  into  contact  with  the  eye.  Just  as  soon  as  the 
contact  is  noticed,  if  the  circumstances  permit,  the  eye  should  be 
thoroughly  cleansed  with  sterile  water  or  a  boric  acid  solution. 
However,  if,  in  spite  of  all  care,  the  irritation  shows  after  a  day  or 
two,  a  drop  or  two  of  cocain  (one  grain  to  the  ounce)  may  be  in- 
stilled into  the  eye  every  four  to  six  hours,  and  during  the  intervals 
frequent  irrigations  of  boric  acid  solution  may  be  used. 

Soreness  of  the  Jaw. — This  condition  we  have  not  seen  occur  in 
children,  although  it  is  common  enough  among  adults  when  the  anes- 
thetist has  been  compelled  to  force  the  jaw  forward. 

Soreness  of  the  Tongue. — This  depends  almost  entirely  upon  the 
mechanical  injury  which  takes  place,  no  matter  how  carefully  re- 
traction of  the  tongue  may  be  done  during  the  administration  of  an 
anesthetic. 

Usually  the  most  ordinary  measures  of  cleanliness  and  rest  will 
result  in  immediate  relief,  but,  if  sloughing  occurs,  it  may  be  neces- 
sary to  resort  to  such  measures  as  the  use  of  a  10  to  15  per  cent, 
solution  of  nitrate  of  silver,  or  some  other  local  treatment  of  the 
sloughing  surface. 


70 

Paralysis. — Paralysis  may  occur  as  the  direct  result  of  prolonged 
or  firm  pressure  over  the  limbs  or  may  even  be  partial  from  a  strained 
posture  of  a  limb  while  under  the  anesthetic.  The  prognosis  of  such 
pressure  paralysis  is  always  good  and  in  a  few  days,  or,  at  most,  a 
few  weeks,  it  entirely  disappears.  The  treatment  consists  of  per- 
sistent massage,  the  use  of  electricity,  or  the  application  of  the  Bier 
constriction  once  daily. 

While  very  uncommon,  there  seems  to  be  good  evidence  to  sup- 
port the  statement  that,  despite  the  most  careful  handling  of  the 
child  while  under  the  anesthetic,  paralysis  of  a  central  origin  may 
occur  as  the  direct  result  of  the  administration  of  the  anesthetic. 
This  latter  can  in  no  way  be  avoided. 

Burns. — Burns  of  a  very  slight  degree  may  occur  as  a  direct 
result  of  contact  of  the  anesthetic  (especially  chloroform)  with  the 
tissues  about  the  mouth.  To  avoid  these  burns  means  to  avoid  the 
contact. 

Burns  of  a  more  serious  nature  are  liable  to  occur  if  hot-water 
bags  or  bottles  are  used  and  careful  watching  is  neglected.  The 
post-anesthetic  state  of  the  child  is  such  that  no  complaint  will  be 
immediately  made  of  excessive  heat,  and  before  such  complaint  is 
made  the  damage  is  frequently  serious. 

Pneumonia. — There   are    several    factors  which   contribute   very 
largely  to  the  occurrence  of  post-anesthetic  pneumonia. 

(a)  First  and  foremost  in  their  production  is  the  presence  of 
even  a  slight  bronchitis  in  the  child  subjected  to  the  anesthetic  or  to 
any  surgical  procedure. 

(b)  Insufficient  protection  to  the  surface  of  the  body  during  and 
immediately  following  a  surgical  procedure. 

(c)  Prolonged  lying  in  one  position  after  operation. 

(d)  Imperfect  or  careless  anesthesia. 

(e)  Neglect  of  the  toilet  of  the  mouth  before  the  administration 
of  the  anesthetic. 

We  have  never  seen  any  but  a  bronchopneumonia  occurring  in 
children  after  anesthesia  which  could  be  directly  attributed  to  the 
anesthetic.  The  instances  in  which  a  lobar  pneumonia  has  occurred 
have  been  somewhat  rare  and  a  careful  resume  of  the  historv  indi- 


COLD,    FREEZING 


71 


cates  that  the  lobar  pneumonia  was  merely  a  coincidence  and  not 
directly  related  to  the  anesthesia. 

Not  uncommonly,  the  supposed  post-anesthetic  pneumonias  are 
the  result  of  mistaken  diagnoses.  For  instance,  it  has  occurred  sev- 
eral times  in  our  hospital  service  that  children  have  been  sent  in  for 
an  immediate  appendectomy  when  the  real  disease  was  not  appen- 
dicitis but  a  lobar  pneumonia  with  masked  physical  signs.  If  such 
cases  are  operated  upon  and  the  appendix  found  normal,  the  subse- 
quent rapid  appearance  of  more  definite  signs  of  pneumonia  is 
blamed  to  the  anesthetic,  when  such  is  not  actually  the  case. 


CHAPTEE  XII 


LOCAL  ANESTHESIA 


Cold;  Freezing. — The  influence  of  even  slight  degrees  of  cold  in 
producing  a  local  and  short  anesthesia  is  somewhat  marked  in  chil- 
dren. If  the  object  of  the  surgeon  is  only  to  secure  a  slight  effect, 


FIG.  28. — FIBST  STEP  IN  INFILTRATION  ANESTHESIA. 

As  the  part  is  steadied  with  one  hand,  the  injection  is  made  until  a  considerable 
area  is  infiltrated. 


72  LOCAL  ANESTHESIA 

the  application  of  ice  alone  or  a  mixture  of  ice  and  salt  will 
rapidly  benumb  the  skin  so  that  but  little  pain  will  be  felt  during 
a  short,  quick  operation.  The  local  spray  of  ethyl  chlorid  or  of 
ether  will  accomplish  similar  results.  However,  the  pain  which  is 
experienced  when  the  part  is  long  subjected  to  the  influence  of  cold 
and  the  benumbing  effect  is  passing  away  is  sometimes  so  severe 
as  to  cause  real  suffering.  In  prolonged  application  of  cold  or 


FIG.  29. — SKCOND  STEP  IN  INFILTRATION  ANESTHESIA. 

The  second  and  subsequent  injections  are  made  so  that  the  edges  of  each  infiltrated 
area  slightly  overlap. 

actual  freezing  there  is  always  the  danger  of  devitalization  of  the 
tissues  with  possible  serious  after-results. 

With  the  use  of  ice  or  the  ice  and  salt  mixture  it  is,  of  course, 
impossible  to  secure  a  sterile  field  for  operation,  therefore  this  method 
is  limited  in  its  use. 

Infiltration. — The  use  of  cocain  upon  the  mucous  surface  has  a 
wide  range  of  usefulness  in  children.  Foreign  bodies  may  thus  be 
removed  with  certainty  and  without  pain  and  in  the  simpler  manipu- 
lations or  operations  about  the  nose,  throat,  eyes,  rectum,  and  urethra 
its  use  is  invaluable. 


INFILTRATION  73 

Novocain,  which  is  far  less  toxic  than  cocain,  may  be  used  in 
its  stead. 

Eucain  is  also  less  toxic  than  cocain  and  may  be  substituted 
for  it. 

Local  infiltration  anesthesia  has  a  wider  range  of  usefulness 
than  is  commonly  supposed.  Its  chief  objection  is  the  time  required 
to  properly  produce  it.  Connective  tissue  may  thus  be  benumbed  suc- 
cessively by  the  injection  of  normal  salt  solution  or  of  cocain  and 
adrenalin. 

Many  of  the  strictly  localized  and  minor  operations  may  be 
undertaken  under  its  use. 

The  local  use  of  cocain  subcutaneously  may,  in  some  instances, 
be  of  much  value,  but  the  dangers  consequent  upon  the  lack  of 
perfect  control  of  the  child  must  always  be  borne  in  mind. 

In  a  few  instances,  when  combined  with  nerve  blocking  by  the 
injections  of  the  cocain  about  the  nerve,  as  well  as  subcutaneously,  it 
has  proved  effective. 

The  use  of  quinin  and  urea  is  too  uncertain  for  extended  use 
in  childhood. 


SECTION  IV 

THE  OPERATION 

CHAPTER  XIII 

PKEPARATION  FOB  THE  OPERATION 

Barring  those  instances  which  can  be  safely  considered  as  emerg- 
ency surgery,  there  should  be  a  very  careful  preparation  for  the  opera- 
tive procedure,  and  this  must  be  planned  according  to  some  definite 
scheme,  so  that  no  detail  may  be  overlooked.  The  importance  of 
thorough  preparation  will  not  be  fully  appreciated  by  the  surgeon  un- 
til the  results  of  a  well-planned  operative  procedure  are  compared 
with  the  results  of  one  of  similar  magnitude  performed  as  an  emerg- 
ency. 

We  are  not  unmindful  of  the  fact  that  most  surgeons  working  in 
institutions  in  which  there  is  a  considerable  amount  of  accident  or 
emergency  surgery  have  the  experience  that  the  unprepared  cases 
submitted  to  operation  seem  to  do  almost  equally  well  with  the  pre- 
pared ones.  This  is  notably  true  in  the  case  of  children.  But  the 
fault  has  always  been  with  the  kind  and  degree  of  preparation.  We 
are  convinced  that  a  child  may  be  too  thoroughly  dosed  and  coddled 
in  anticipation  of  some  operative  procedure  and  this  may  parade 
under  the  name  of  preparation.  Now,  preparation  does  not  neces- 
sarily mean  the  institution  of  starvation  methods  and  prolonged  or 
severe  catharsis,  both  of  which  are  the  usual  methods. 

The  idea  of  preparation  is  not  to  dose  the  child  or  to  rapidly 
compel  a  decided  change  in  its  habits  or  even  to  immediately  restrict 
its  usual  activity,  but  it  is  to  so  safeguard  the  operative  procedure 
that  without  too  much  alteration  of  the  child's  life  the  very  best 
results  are  secured  with  the  least  possible  interference  with  the 
normal  life  of  the  child.  Naturally,  there  is  a  wide  range  of  factors 

74 


PREPARATION    OF    THE    PATIENT  75 

which  will  operate  differently  in  different  cases,  so  that,  considering; 
environment  and  all  allied  factors  and  the  personal  experience  of 
the  individual  operator,  nothing  but  the  most  general  rules  can  rea- 
sonably apply.  Each  surgical  case  is  a  case  by  itself  and  this  point 
is  emphasized  when  we  recall  the  teachings  of  all  skilled  podiatrists : 
that  every  child  must  be  individualized. 


PREPARATION   OP   THE   PATIENT 

Physical  Condition.  — Many  of  the  things  which  have  been  noted 
by  the  history  and  examination  of  the  child  will  have  offered  consider- 
able information  in  regard  to  its  general  condition.  But  in  addition 
to  this  there  must  be  an  intimacy  with  the  physical  condition  of 
the  child  which  will  allow  of  advantage  being  taken  of  every  factor 
which  influences  the  prognosis. 

Children  are  especially  liable  to  infection  and  therefore  much 
caution  is  necessary  to  exclude  the  possibility  of  the  child  being  in 
the  incubation  stage  of  one  of  the  acute  infectious  exanthemata.  The 
development  of  diphtheria,  measles,  scarlet  fever,  or  smallpox,  coin- 
cident with  or  closely  following  an  operation,  will  often  determine 
the  result.  Thus,  in  an  operation  in  which  the  time  of  the  procedure 
is  elective,  if  there  has  been  the  possibility  of  exposure,  the  opera- 
tion should  be  delayed  until  the  incubation  period  is  past. 

The  time  that  has  been  taken  to  bring  out  clearly  the  history  of 
possible  exposure  is  never  wasted.  To  act  intelligently  means  that 
one  must  have  a  clear  idea  of  the  various  incubation  periods.  These 
periods  are  as  follows : 

Measles :  from  the  time  of  exposure  until  the  catarrhal  symptoms 
first  appear  there  is  usually  an  interval  of  eleven  days ;  then  follows 
the  stage  of  invasion,  which  lasts  for  about  three  days. 

Kubella :   from  fourteen  to  eighteen  days. 

Scarlet  fever:  from  six  hours  to  five  or  six  days;  the  shorter 
periods  being  much  more  common  than  the  longer  ones. 

Variola '.  the  average  is  twelve  days. 

Varicella :  fourteen  days. 


76  PREPARATION  FOR  THE  OPERATION 

Diphtheria:  There  are  present  in  the  mouths  and  throats  of 
many  children  who  still  remain  healthy  the  Klebs-Loefflcr  bacilli. 
Just  as  long  as  such  a  child  is  protected  from  any  shock  or  injury 
these  fail  to  cause  any  lesion.  But  coincident  with  anything  which 
depresses  the  child's  system  there  is  usually  a  rapid  increase  in 
the  bacilli.  It  will  thus  be  readily  seen  that  the  only  safe  procedure 
in  an  elective  case  is  to  take  a  culture  from  the  throat  and  demon- 
strate either  the  presence  or  the  absence  of  the  bacilli. 

Cerebrospinal  meningitis  (epidemic)  :  two  to  four  days. 

Erysipelas :  twelve  hours  to  three  days. 

'If  vaccination  has  been  performed,  three  weeks  should  elapse 
before  the  operation  is  undertaken,  except  in  emergency. 

There  are  many  other  factors  which  must  be  considered  also  in 
elective  cases.  The  attempt  to  correct  a  deformity,  remove  a  slow- 
growing  tumor,  or  subject  the  ill-nourished,  anemic  child  to  other 
surgical  procedure  may  prove  disastrous,  or  in  any  event  will  not 
be  as  successful  as  the  operation  done  under  more  favoring  cir- 
cumstances. 

The  surgeon  should  refer  the  child  to  some  one  skilled  in  the 
details  which  are  so  essential  in  bringing  such  a  child  into  the  best 
possible  physical  condition  to  withstand  the  strain  of  an  operative 
procedure  and  do  it  successfully. 

Disease  which  has  no  direct  bearing  upon  the  surgical  condition 
must  receive  attention,  as  it  may  seriously  influence  the  outcome 
of  an  otherwise  successful  mechanical  result.  We  recall  very  dis- 
tinctly an  abdominal  operation  undertaken  against  our  advice  in  a 
child  suffering  from  a  mild  form  of  pertussis.  Immediately  fol- 
lowing the  operation  the  depression  of  the  child's  nervous  system  was 
so  marked  that  the  spasms  of  coughing  became  more  frequent  and 
severe  and  the  abdominal  wound  was  torn  open.  The  child  hovered 
between  life  and  death  for  days  and,  although  the  technique  of  the 
operation  was  perfect,  the  results  were  nearly  fatal. 

Thus  we  see  that  any  constitutional  disease  enters  very  largely 
into  the  problem  as  to  when  to  operate. 

We  must,  however,  speak  particularly  of  hemophilia,  as  it  has 
such  an  important  bearing  upon  the  outcome  of  even  the  most 


PREPARATION    OF    THE    PATIENT  77 

simple  surgical  procedure  which  may  result  in  hemorrhage.      (See 
page  112.) 

We  do  not  think  it  is  necessary  to  do  more  than  emphasize 
the  fact  that  the  examination  of  the  various  organs,  and  particularly 
the  heart,  the  lungs,  kidneys,  and  blood,  should  proceed  along 
somewhat  similar  lines  as  in  adult  cases.  But, .  if  anything,  there 
must  be  more  care  given  to  this  examination,  and  unless  the  surgeon 
is  particularly  skilled  in  this  work  the  best  interests  of  the  child 
call-  for  other  assistance. 

Urine. — The  difficulty  which  sometimes  attends  the  securing  of 
a  specimen  of  the  urine  should  be  no  deterrent  of  this  procedure  in 
every  case.  In  the  male  the  urine  may  be  collected  by  the  use  of  a 
condom  fastened  over  the  penis,  and  in  females  it  may  be  collected 
in  a  small  cup  or  vessel  made  for  that  purpose.  When  only  a  small 
quantity  is  required  (as  to  determine  the  presence  of  albumin)  a 
small  piece  of  absorbent  cotton  may  be  used.  It  happens  at  times 
that  catheterization  becomes  necessary,  and  in  such  instances  only 
the  small  instrument  should  be  used  (as  No.  6,  American  scale). 

Blood. — The  presence  or  absence  of  anemia  in  the  child  cannot 
be  determined  simply  by  observation  but  is  only  proved  by  the  de- 
termination of  some  blood  change.  Pallor  of  the  skin  and  the  mucous 
surfaces,  if  gradually  developed,  is  usually  a  very  suggestive  sign 
of  a  reduction  in  the  number  of  blood  cells  and  of  hemoglobin,  but  it 
is  safer  to  confirm  this  by  other  means. 

When  it  is  decided  that  anemia  is  present,  it  is  necessary  to  go 
1  icy ond  this  and  determine  whether  it  is  primary  or  secondary. 
Most  of  the  anemias  occurring  during  childhood  are  secondary  and 
therefore  we  must  find  out  whether  the  blood  condition  is  not  depend- 
ent upon  nephritis,  tuberculosis,  rachitis,  malnutrition,  some  suppura- 
tive  process,  or  other  condition. 

The  influence  of  chronic  poisonings,  as  by  arsenic,  mercury,  etc., 
must  be  remembered. 

If  the  hemoglobin  is  low,  the  giving  of  the  anesthetic  becomes 
a  greater  danger,  collapse  is  much  more  liable  to  occur,  and  con- 
valescence and  repair  are  hindered. 

If  the  hemoglobin  percentage  is  below  sixty,  any  operative  pro- 


78        PREPARATION  FOR  THE  OPERATION 

cedure  should  be  only  undertaken  under  unusual  precautions  to  safe- 
guard the  child  against  shock  and  hemorrhage. 

Jaundice. — If  there  are  any  evidences  of  jaundice  present  in 
the  child,  there  is  apt  to  be  an  unusual  loss  of  blood  even  under 
the  ordinary  procedures,  and  it  may  be  wise  in  such  instances  to 
test  its  coagulability. 

Laxative. — It  is  not  always  possible  to  thoroughly  clear  out  the 
intestinal  tract  with  the  administration  of  a  single  dose  of  a  laxa- 
tive. Thorough  cleansing  may  require  a  careful  regulation  of-  the 
diet  for  two  or  three  days  and,  with  that,  the  intelligent  use  of  a 
laxative  or  cathartic.  However,  it  is  always  advisable  to  admin- 
ister a  few  hours  before  the  operation  a  soapsuds  enema,  or  one 
consisting  of  magnesia  sulphate,  one  ounce,  glycerin,  two  ounces,  and 
warm  water,  one  pint.  This  latter  is  particularly .  serviceable  in 
surgery  about  the  rectum,  as  practically  all  of  the  mucus  is  dis- 
solved and  removed  by  it.  In  cases  in  which  much  abdominal  dis- 
tention  is  present  turpentine  may  be  added  to  the  enema  (one 
dram  to  each  pint).  In  abdominal  operations  an  enema  of  milk 
and  molasses  is  serviceable  in  older  children. 

Digestive  Disturbances. — The  great  liability  of  infants  and  young 
children  to  suffer  from  frequent  disturbances  of  the  digestive  organs 
should  excite  the  interest  and  attention  of  the  surgeon  because  the 
perfect  performance  of  the  nutritive  functions  is  essential  to  suc- 
cessful surgery.  It  is  readily  observed  that  a  gas-distended  stomach 
or  intestine  will  interfere,  perhaps  seriously,  with  the  perfect  per- 
formance of  an  operation  upon  the  abdomen.  But  this  is  a  mat- 
ter of  interference  with  technique;  there  is  a  more  serious  aspect, 
and  that  relates  to  the  anesthetic.  Many  of  the  failures  to  control 
the  anesthesia  are  directly  attributable  to  this  factor.  Irrespective 
of  technique  or  the  anesthetic,  the  convalescence  of  the  young  child 
or  infant  may  be  seriously  complicated  by  an  acute  digestive  dis- 
turbance of  either  stomach  or  intestine.  If  removal  from  the  home 
becomes  necessary,  it  may  entail  some  change  in  the  diet,  and  this 
removal  and  change  should  be  sufficiently  long  to  demonstrate  its 
safety,  whenever  practical. 

Water  Drinking. — Kather  free  water  drinking  should  be  encour- 


PREPARATION    OF    THE    FIELD    OF  OPERATION      79 

aged,  for  it  seems  to  act  favorably  upon  elimination  through  the 
kidneys  and  the  skin. 

Bathing. — Bathing  contributes  not  a  little  to  the  final  result,  for 
frequently  the  necessary  dressings  applied  after  an  operation  cover 
so  much  of  the  child's  body  that  free  bathing  or  sponging  subse- 
quent to  the  operation  is  impractical. 

Toilet  of  Mouth.- — The  toilet  of  the  mouth  should  be  most  rigor- 
ous, and  yet  there  must  be  extreme  care  in  the  case  of  infants  that 
the  delicate  mucous  membrane  is  not  injured  in  any  way.  It  is  not 
uncommon  to  find  in  infants  minute  patches  of  commencing  stoma- 
titis, and  whenever  possible  these  should  receive  adequate  attention 
before  the  infant  is  subjected  to  operation.  Neglect  in  this  particu- 
lar may  lead  to  serious  complications,  for  in  any  uncared-for  mouth 
there  may  exist  organisms  which  will  develop  rapidly  under  the 
favoring  irritation  caused  by  ether  particularly. 

Practically  all  the  diseases  of  the  mouth  are  the  result  of  trauma 
or  of  infection.  The  cavity  is  certainly  an  ideal  breeding  place  for 
all  kinds  of  organisms,  and"  it  is  only  by  the  action  of  the  secretions 
and  the  constant  cleansing  which  normally  goes  on  that  disease  is  not 
more  common.  Probably  the  secretions  act  more  emphatically  in 
preventing  disease  than  we  are  aware  of,  for  clinically  it  is  a  fact 
that  with  diminished  secretion,  or  in  the  presence  of  conditions  which 
disturb  the  composition  of  that  secretion,  diseases  of  the  mouth  are 
more  prevalent. 


PREPARATION    OF    THE    FIELD    OF    OPERATION 

Until  the  child  is  about  to  be  operated  upon,  the  field  of  opera- 
tion should  not  receive  any  more  attention  than  the  warm  cleansing 
bath,  which  not  alone  considers  the  field  of  operation  but  is  a  general 
one.  There  are  good  reasons  for  restricting  undue  preparation.  The 
child's  skin  is  tender  and  very  easily  injured  and  becomes  easily 
the  site  of  an  infection.  Shaving  or  vigorous  rubbing  done  many 
hours  before  the  operation  may  cause  almost  imperceptible  injuries 
which  favor  bacterial  growth,  arid  the  heat  and  the  moisture  of  a 


80  PREPARATION  FOR  THE  OPERATION 

dressing  left  on  the  surface  for  many  hours  need  no  elaboration  of 
ours  to  emphasize  their  possibilities  for  harm.  Such  preparations 
should  be  left  until  shortly  before  the  operation. 

All  scrubbing  of  the  skin  should  be  done  thoroughly,  but  withal 
gently.  Not  uncommonly  we  find  in  the  field  of  operation  or  closely 
approximating  it  a  patch  of  eczema,  and  the  question  arises  as  to 
how  to  dispose  of  it  as  a  factor.  If  eczema  is  moderate  or  severe  in 
a  child,  the  operation  should  be  postponed,  if  possible,  until  the 
effect  of  direct  treatment  of  this  troublesome  condition  can  be  se- 
cured. However,  if  the  operative  procedure  must  be  accomplished, 
then  there  are  two  ways  of  attacking  it.  If  the  eczematous  patch  is 
directly  in  the  field  of  operation,  it  should  be  curetted  and  painted 
with  tincture  of  iodin  just  previous  to  the  operation.  If  simply 
close  to  the  operative  field,  the  patch  should  be  isolated  by  gauze  and 
collodion.  We  recall  one  instance  in  Avhich  the  operative  field  was 
so  thickly  studded  with  these  patches  that  the  whole  of  the  surface 
was  covered  with  three  layers  of  gauze  soaked  in  collodin  (after 
removal  of  all  scabs  and  debris)  and  the  incision  carried  through  the 
gauze  and  skin.  This  offered  us  a  protected  field  which  we  felt 
that  we  could  not  secure  in  any  other  way.  It  more  certainly  than 
any  other  method  reduced  the  probability  of  foreign  material  being 
carried  into  the  wound.  What  we  have  advised  in  regard  to  eczema- 
tous patches  would  apply  in  a  measure  to  those  with  broken  skin. 

The  stronger  antiseptics  cannot  be  used  on  a  child's  skin,  there- 
fore we  are  very  much  restricted  in  our  choice  of  these  agents. 

The  foregoing  observations,  of  course,  apply  only  in  a  general 
way;  there  must  be  special  preparation  for  special  areas  and  even 
for  unusual  or  special  operations. 


EXAMINATION    OF    PATIENT 

Examination  of  the  Heart.  —This  should  be  made  by  the  surgeon 
or  his  assistant  in  every  case  and  must  be  independent  of  the  similar 
examination  which  must  be  a  routine  (routine  as  regards  its  occur- 
rence and  not  as  regards  its  preciseness)  method  of  the  anesthetist, 


EXAMINATION    OF    PATIENT 


81 


although  the  two  examinations  should  be  compared.     The  examina- 
tion differs  only  in  some  details  from  that  of  the  adult  heart,  and 


FIG.  30. — RELATIVE  CARDIAC  DULLNESS 
(OUTLINED)  AND  ABSOLUTE  CARDIAC 
DULLNESS  (SHADED)  IN  AN  INFANT 
OF  ONE  YEAH. 


FIG.  31. — AREA  OF  RELATIVE  CARDIAC 
DULLNESS  (OUTLINED)  AND  ABSOLUTE 
CARDIAC  DULLNESS  (SHADED)  IN 
CHILD  OF  Six  YEARS. 


while  there  exist  anatomic  and  physiologic  differences,  the  difficul- 
ties which  attend  the  examination  of  the  child's  heart  are  not  those 
of  method  but  those  of  deduc- 
tion.      These     differences     are 
thoroughly     discussed     in     the 
works    upon    this    special    sub- 
ject. 

Provided  that  compensation 
is  established,  valvular  disease 
of  the  heart  is  no  contraindi- 
cation to  the  administration  of 
a  general  anesthetic  or  the 
performance  of  a  major  sur- 
gical operation. 

Examination     of     the  Chest. 
—Inspection  will  frequently  give  a  clew  as  to  the  nutritional  state 
of  the  patient,   an  insufficient  subcutaneous  covering  of  the  bony 
framework  indicating  some  general  weakness  or  malnutrition. 


FIG.  32. — AREA  OF  RELATIVE  CARDIAC 
DULLNESS  (OUTLINED)  AND  ABSOLUTE 
CARDIAC  DULLNESS  (SHADED)  IN 
CHILD  OF  TWELVE  YEARS. 


PREPARATION  FOR  THE  OPERATION 


A  flat  chest  is  commonly  associated  with  a  tuberculous  history. 
Pigeon  breast  chest  indicates  that  there  is  some  persistent  interfer- 
ence with  free  respiration, 
or  it  may  occur  in  rachitis. 
In  the  rachitic  chest  there 
is  a  shortened  chest  with 
prominence  of  the  sternum 
and  beading  of  the  ribs 
and  the  costal  angle  is 
usually  quite  acute.  The 
funnel  chest  has  no  special 
significance. 

In  the  emphysematous 
chest  the  aiiteroposterior 
diameter  is  increased,  the 
sternum  perceptibly 
arched,  the  ribs  thickened 
and  running  horizontally 
outward,  making  a  wide 
subcostal  angle. 

An  error  that  is  frequently  made  is  in  mistaking  a  similar  condi- 
tion which  occurs  in  kyphosis,  but  in  the  latter  there  is  no  evidence 
of  chest  disease  and  the  ribs  are  not  thickened. 

Unilateral  enlargement  is  most  noticeable  at  the  base  and  is 
generally  the  result  of  an  accumulation  of  gas  or  fluid  in  one  plcural 
cavity,  but  may  be  due  to  compensation  on  account  of  disease  of  the 
other  lung.  When  compensatory,  the  affected  lung  is  smaller  than 
normal.  When  not  due  to  compen- 
sation, the  ribs  are  elevated,  the 
side  more  rounded  and  the  inter- 
spaces usually  obliterated. 

Unilateral   contraction   is   due 
usually  to   pleuritic  adhesions   or 
may  be  due  to  a  collapsed  lung.    If 
abscess  is  formed,  the  shoulder  droops  and  there  may  be  more  or  less 
spinal  curvature. 


FIG.    33. — CONDOM  TIED  OVEH  PENIS  TO  COLLECT 
SPECIMEN  OF  THE  URINE  FOR  EXAMINATION. 


FIG.  34. — CHAPIN  URINAL,  FOR  THE  COL- 
LECTION OF  SPECIMENS  FOR  EXAMI- 
NATION. 


EXAMINATION    OF    PATIENT 


83 


It  requires  care  under  this  condition  to  differentiate  scoliosis  from 
primary  vertebral  disease. 

Precordial  bulging  is  usually  dependent  upon  an  enlarged  heart, 
but  less  commonly  occurs  with  large  pericardial  effusions  (rare  in 
children),  aneurysm,  and  tumor. 

Hypochondrium  bulging  occurs  with  large  effusions  into  the 
pleura  and  in  hepatic  and  subphrenic  abscess,  but  if  right  sided  may 
be  due  to  liver  enlargement. 

In  each  instance  a  very  careful  examination  must  be  made  of  the 
chest,  for,  in  children,  diseases  of  the  bronchi  and  lungs  are  very 


FIG.  35. — CHAPIN  URINAL  IN  POSITION. 

common  and  easily  made  worse,  and  at  best  are  liable  to  lead  to 
serious  consequences,  particularly  when  complicated  by  injury,  the 
administration  of  an  anesthetic,  or  the  shock  of  even  the  minor  surgi- 
cal procedures. 

Examination  of  the  TJrine. — For  the  purposes  of  smooth  surgery 
the  examination  of  the  urine  in  young  subjects  should  be  even  more 
painstaking  than  in  adults,  because  of  the  fact  that,  in  the  former, 
disease  often  has  its  beginnings  insidiously. 

Hematuria  must  not  be  confounded  with  hemoglobinuria,  which 
latter  is  due  simply  to  the  presence  of  blood-pigment  in  the  urine, 


84  THE  CONTROL  OF  HEMORRHAGE 

while  hematuria  is  evidenced  by  the  actual  presence  of  blood.  The 
common  local  causes  of  hematuria  in  children  are  trauma  of  the 
various  kinds,  calculi,-  jnew  growths,  congestion  or  inflammations 
anywhere  in  the  genitourinary  tract,  and  ruptured  veins.  The  gen- 
eral causes  are  chiefly  hemorrhagic  diseases  of  the  new-born,  purpura, 
scorbutus,  malaria,  syphilis,  tuberculosis,  nephritis,  and  hemophilia. 
The  use  of  certain  drugs  may  also  cause  it. 

Pyuria  may  be  due  to  the  pus  coming  from  any  portion  of  the 
genitourinary  tract,  but  the  most  frequent  source  in  children  is  the 
pelvis  of  the  kidney.  Next  in  frequency  we  find  that  the  pus  comes 
from  an  outside  source,  as  when  an  abscess  opens  into  the  tract. 
An  acute  pyuria  suggests  more  often  than  anything  else  a  pyelitis, 
while  chronic  pyuria  is  strongly  indicative  of  tuberculosis  of  the 
kidney. 

The  details  of  the  urinary  examination  are  similar  to  those  of 
adults ;  the  thing  to  be  emphasized  is  the  relatively  greater  import- 
ance of  such  examination  in  childhood. 


CHAPTEK  XIV 

THE  CONTROL  OF  HEMORRHAGE 

Without  going  into  a  lengthy  and  unnecessary  discussion  of  prob- 
lems in  regard  to  the  circulatory  apparatus  in  children,  it  is  only 
needful  that  the  surgeon  clearly  and  constantly  appreciate  one  fact : 
that  children  stand  hemorrhage  badly.  In  a  survey  of  the  varied 
theories  and  possibilities  which  are  advanced  by  various  writers  in 
regard  to  the  subject,  we  find  that  the  anatomic  and  physiologic 
peculiarities  which  are  recognized  all  point  to  three  very  definite 
clinical  facts  and  these  are  what  are  of  interest. 

(1)  There  is  a  diminished  blood  pressure  in  childhood. 

(2)  The  circulation  of  the  blood  stream  is  very  rapid. 

(3)  The  pulse  is  rapid  and  easily  disturbed. 
These  clinical  facts  emphasize  the  operative  need. 

It  must  be  clearly  understood  that  the  surgeon  who  deals  with 


DELAYED    HEMOBRHAGE 


85 


the  child  must  make  every  provision  against  the  loss  of  even  the 
smallest  quantities  of  blood.  This  entails  considerable  care  in 
the  preparation  for  any  operative  procedure  that  may  be  necessary. 
The  Esmarch  bandage  should  be  used  whenever  practical.  It  is  a 
grave  mistake  not  to  have  an  abundant  supply  of  hemostatic  forceps 
and  these  should  be  of  such  size  that  they  will  not  involve  in  their 
grasp  too  much  of  the  tissues.  The  mosquito  forceps  are  particularly 
serviceable  for  this  work.  It  is  an  excellent  plan  to  have  each  vessel 
grasped  between  forceps  before 
its  division.  As  pressure  alone 
acts  favorably  upon  the  con- 
tractility of  the  vessels,  the  use 
of  ligatures  is  not  as  essential 
as  in  adults.  For  surfaces  that 
ooze  there  is  nothing  better 
than  gentle  pressure  with  hot 
gauze  sponges,  or,  if  this  fail 
to  give  prompt  results,  a  hot 
normal  salt  solution  may  be 
used.  Provision  should  be 
made  before  the  operation  for 
the  possible  necessity  of  pack- 
ing cavities  with  suitable 
gauze,  the  use  of  the  cautery, 
or  any  other  known  method  to 
conserve  the  loss  of  blood. 

Primary  Hemorrhage. — The 
recognition  and  treatment  of 
this  condition  do  not  differ  in  any  material  way  from  a  similar  con- 
dition in  adults;  however,  there  is  ever  present  the  danger  arising 
from  an  unsuspected  case  of  hemophilia. 

Delayed  Hemorrhage. — This  is  the  type  of  hemorrhage  that  oc- 
curs after  recovery  from  the  anesthesia  and  may  occur  within  a  few 
hours  or  be  delayed  for  nearly  a  week. 

The  symptoms  vary  with  the  rapidity  with  which  blood  is  lost 
and  also  its  amount.  Delayed  hemorrhage  is  always  a  vastly  more 


FIG.  36 — MOSQUITO  FORCEPS. 


86  THE  CONTROL  OF  HEMORRHAGE 

serious  matter  in  children  than  in  adults.  Very  quickly  there  is 
added  the  full  symptomatology  of  shock  and  it  only  requires  a  small 
amount  of  blood  (in  some  instances  we  have  noted  it  after  a  loss  of 
one  or  two  ounces)  to  bring  this  about. 

It  is  rare  in  these  days  of  careful  technique  to  observe  the 
quickly  fatal  cases  in  which  the  child  will  bleed  to  death  within  a 
few  minutes.  Generally  the  picture  is  somewhat  like  this:  the 
child  several  hours  or  days  after  operation  shows  an  undue  restless- 
ness with  a  small,  weak  pulse.  With  increasing  restlessness  there  is 
some  dyspnea,  but  neither  of  these  may  be  very  pronounced.  The 
pulse,  however,  continues  to  increase  and  out  of  all  proportion  to 
other  symptoms.  This  symptomatology  may  be  all  that  is  present 
and  should  always  be  considered  by  the  surgeon  as  sufficient  cause 
for  a  most  searching  examination  of  the  child  for  hemorrhage. 

There  is  a  marked  difference  between  the  symptoms  of  delayed 
hemorrhage  in  adults  and  in  children ;  in  the  former  the  symptoma- 
tology expresses  itself  as  clearly  due  to  loss  of  blood,  but  in  the 
latter  it  is  not  so  expressed  but  occurs  as  the  result  of  very  early 
shock.  Therefore,  while  in  adults  we  usually  encounter  pallor, 
extreme  nervousness,  thirst,  air  hunger,  and  great  anxiety,  these 
may  be  entirely  absent  in  children  and  the  symptomatology  of  shock 
alone  be  present  (see  page  106). 

The  diagnosis  from  delayed  shock  is  exceedingly  difficult  and 
we  have  observed  several  instances  in  which  this  diagnosis  has  been 
made  and  the  autopsy  subsequently  revealed  the  fact  of  delayed 
hemorrhage,  which  was  unsuspected. 

The  causes  are  somewhat  similar  to  those  of  later  life.  The 
principal  ones  to  remember  are: 

(a)  The  more  or  less  perfect  closure  of  small  bleeding  points 
by  clot  and  its  subsequent  dislodgment  after  the  wound  has  been 
dressed. 

(b)  Hernatoma  subsequent  to  injury  of  a  vessel  during  closure 
of  the  wound. 

(c)  Much  increased  blood  pressure  after  an  operative  procedure, 
causing  what  was  an  apparently  well-dried  and  bloodless  surface  to 
begin  oozing. 


CONSTITUTIONAL  TREATMENT  OF  HEMORRHAGE      87 

(d)  Poorly  applied  or  poorly  made  sutures. 

(e)  Friable  tissues. 

The  treatment  is  based  upon  exactly  the  same  principles  as 
govern  the  care  of  similar  cases  in  adults. 

Secondary  Hemorrhage. — This  is  hemorrhage  which  is  due  to 
erosion  of  a  vessel  through  the  agency  of  a  septic  process  and  there- 
fore is  observed  several  days  after  the  operation.  It  is  largely  a 
relic  of  the  days  in  which  aseptic  surgery  was  not  possible  and  is 
exceedingly  rare  at  the  present  day. 

Constitutional  Treatment  of  Hemorrhage. — The  constitutional  treat- 
ment of  hemorrhage  must  always  be  added  to  those  measures  which 
are  instituted  to  control  the  bleeding.  Under  the  existing  circum- 
stances, care  must  be  exercised  to  avoid  increasing  the  arterial  ten- 
sion too  much,  either  through  the  use  of  vasoconstrictors  or  by  the 
introduction  into  the  body  (through  the  mouth,  rectum,  subcutan- 
eously,  or  by  transfusion)  of  an  excessive  amount  of  fluid. 

In  children,  the  treatment  after  the  control  of  the  hemorrhage  is 
mainly  the  treatment  of  shock  (see  page  109). 

There  are  several  features  of  the  treatment  which  should  receive 
the  consideration  of  the  surgeon  and  these  might  be  summarizd 
as  follows:  ' 

THE    IMMEDIATE    DEMANDS 

(a)  Elevate  the  foot  of  the  bed. 

(b)  Eliminate  all  unnecessary  persons,  noise,  light,  and  excite- 
ment from  the  room. 

(c)  Supply  oxygen  by  open  windows  (continuous  method). 

(d)  Maintain  body  heat  by  blankets  and  hot  bottles. 

(e)  Stimulate  cautiously. 


THE   REMOTER   DEMANDS 

(a)   Intravenous,   subcutaneous,  or  rectal  injections  of  normal 
salt  solution  (with  or  without  adrenalin)   as  occasion  demands. 


88  POST-OPERATIVE  CARE 

(b)  Stimulate  more  boldly  than  at  first,   after   most  carefully 
noting  the  effect  of  the  stimulation,  not  alone  upon  the  circulation 
but  also  upon  the  digestion. 

(c)  Add  as  rapidly  as  possible  to  the  diet,  considering  nutritive 
value  of  each  article  of  food,  and  digestive  capacity  of  prime  im- 
portance. 

(d)  Administer  well-selected  tonics  to  correct  the  acute  anemia. 
And,  lastly,  in  rare  instances  it  may  become  necessary  to  con- 
sider the  advisability  of  blood  transfusion. 


CHAPTER  XV 

POST-OPERATIVE  CAEE 

Not  uncommonly  a  considerable  part  of  the  success  of  a  surgical 
procedure  depends  upon  the  post-operative  care  that  the  child 
receives  and  the  responsibility  of  the  surgeon  cannot  reasonably  end 
with  the  completion  of  that  procedure.  It  is  needless  to  discuss  what 
the  common  custom  has  been  in  regard  to  this  matter,  for  it  is  suf- 
ficient to  say  that  the  surgeon  should  have  a  general  supervision 
of  the  convalescence  of  the  child,  or  should  be  allowed  to  transfer 
this  responsibility  to  one  equipped  to  study  and  safeguard  the  child's 
best  physical  interests. 

The  purpose  of  post-operative  care  is  not  primarily  to  nurse  back 
to  health  a  child  that  has  been  sick,  for  that  is  not  commonly  the 
case.  The  child  has  been  wounded,  or,  at  least,  that  is  the  best 
attitude  to  assume  toward  the  patient  and  his  friends ;  the  child  has 
been  wounded  and  the  real  object  of  the  post-operative  care  and 
treatment  is  to  avoid  any  complications  or  to  limit  their  ravages  and 
to  hasten  the  healing  of  the  injured  parts.  Of  course,  the  general 
condition  of  the  child  may  demand  attention  quite  apart  from  the 
injury,  or  there  may  exist  or  arise  disease  or  disturbed  function 
in  special  parts  which  will  require  treatment,  but,  in  the  main,  the 
problem  is  one  of  wound  treatment  and  complication  prophylaxis. 

This  is  the  surgical  viewpoint,  but  the  public  demand  more  than 


DIET    AFTER    OPERATION"  89 

this ;  parents  rightly  expect  the  child  to  be  restored  as  nearly  as  pos- 
sible to  efficient  childhood.  The  problem  of  post-operative  care  is  not 
always  a  surgical  one,  and  if  the  courage  and  skill  of  the  surgeon 
was  more  often  coupled  with  the  judgment  and  training  of  the  skilled 
physician  or  pediatrist,  the  results  would  be  better  and  confidence 
in  surgical  procedures  be  restored. 

The  Room.- — The  room  prepared  for  the  reception  of  the  child 
after  an  operative  or  surgical  procedure  should  be  the  best  ventilated 
and  sunniest  one  that  the  house  affords.  It  must  be  capable  of 
proper  ventilation  and  heating  and  reasonably  near  to  water  and 
toilet  conveniences.  The  furnishings  should  be  as  simple  as  possible 
and  always  selected  with  the  idea  of  the  easy  maintenance  of  proper 
and  adequate  surgical  cleanliness  and  without  the  entailing  of  the 
extra  work  required  by  a  selection  of  more  elaborate  furnishings. 
The  bed  should  be  one  that  can  be  easily  moved  and  which  allows 
of  the  proper  attendance  upon  the  child  from  both  sides  and  without 
disturbing  the  little  patient.  Whenever  possible,  it  is  well  to  supply 
the  bed  with  a  pillow  stuffed  with  oakum,  which  has  been  previously 
exposed  to  the  air  to  eliminate  the  tarry  odor,  because  this  filling 
can  be  readily  removed  and  destroyed.  It  is  no  uncommon  experi- 
ence to  encounter  vomiting,  and  when  this  occurs  the  mere  chang- 
ing of  the -outside  slip  of  the  pillow  does  not  get  rid  of  the  materials 
which  are  soaked  with  the  vomitus  and  are  therefore  surgically  un- 
clean. Oakum  is  cheap,  easily  obtained,  and  readily  destroyed. 

Diet  after  Operation. — The  diet  of  the  child  must,  of  course,  be 
modified  by  the  circumstances  of  age,  the  previous  dietary,  the  na- 
ture of  the  injury,  the  site  of  the  injury,  and  the  nutritional  needs 
of  the  particular  child. 

But  there  are  certain  general  principles  which  must  have  the 
surgeon's  consideration. 

We  need  not  discuss  the  question  of  the  diet  immediately  after 
the  operation  because  this  has  been  considered  under  post-anesthetic 
care. 

The  diet  should  always  be  one  that  is  nourishing  with  the  least 
amount  of  bulk  and  suited  to  the  needs  of  the  particular  child,  for 
some  consideration  must  be  given  to  the  previous  dietary,  no  mat- 


90 


POST-OPERATIVE  CAEE 


ter  how  wrong  it  may  have  been.  Children,  like  adults,  do  not 
easily  fit  themselves  to  standards  of  diet  and  certainly  have  individual 
likes  and  dislikes  which  must  be  considered. 

In  addition,  although  the  diet  may  have  been  wrong,  children  are 
easily  the  victims  of  habit  and  the  attempt  to  radically  change  or 
adjust  their  diet  to  what  it  should  be  without  giving  any  considera- 
tion at  all  to  what  it  has  been,  will  result  in  rebellion  against  the 
innovation  and  the  willful  refusal  to  partake  of  sufficient  nourish- 
ment. Some  few  children  fall  readily  enough  into  our  dietary 


FIG.  37. — CHILD  PROPERLY  ATTENDED  AFTER  THE  OPERATION,  THE  BODY  BEING  ADE- 
QUATELY PROTECTED  AND  THE  VOMITUS  TAKEN  CARE  or. 

schemes,  but  when  they  do  not,  it  is  much  better  to  allow  a  dietary 
which  is  nourishing  and  readily  taken  rather  than  arbitrarily  to 
insist  upon  one  that  is  nearer  the  ideal  but  which  will  be  refused 
by  the  patient. 

If  the  child  has  suffered  much  from  shock  or  hemorrhage,  fluids 
should  be  administered  early  and  freely.  In  abdominal  operations 
or  injuries  it  is  wise  to  rest  the  gastrointestinal  tract  for  several 
hours  and  the  withholding  of  all  food  may  be  necessary.  Operations 
upon  or  injury  of  the  mouth  or  stomach  may  make  rectal  feeding 
necessary  for  some  time. 


91 

There  is  one  article  of  diet  which  is  taken  readily  by  practically 
every  child,  irrespective  of  the  age  or  the  other  circumstances  men- 
tioned, and  that  article  is  milk. 

However,  under  the  conditions  in  which  the  surgical  child  of 
any  age  finds  itself,  the  milk  must  be  modified  so  as  to  supply  the 
required  nutrition  without  undue  disturbance  to  the  digestive  appara- 
tus. Until  the  surgeon  has  had  an  opportunity  to  learn  the  needs 
of  the  child  or  until  the  child  has  had  the  opportunity  to  adjust 
itself  to  the  new  conditions,  we  have  found  that  top-milk  modified 
with  a  sugar  and  a  diluent,  and  perhaps  with  the  addition  of  a  fresh 
egg,  supplies  for  a  long  period  all  of  the  nutrition  and  energy  that 
is  actually  needed,  although  variety  is  lacking.  It,  however,  may 
be  used  as  the  foundation  of  the  diet  for  several  days  with  excellent 
results. 

For  instance,  in  a  child  of  five  or  six  years  of  age  and  of  average 
weight  and  nutrition,  the  following  is  given: 

The  top  sixteen  ounces  from  a  quart  of  milk. 

Sixteen  ounces  of  a  diluent  (water,  or  a  cereal  water,  with  or 
without  the  addition  of  lime  water). 

Sugar  of  milk,  one  to  one  and  one-half  ounces  (to  add  energy 
and  not  merely  as  a  sweetener). 

The  above  to  be  given  in  quantities  suited  to  the  particular 
needs  at  the  time. 

Raw  egg  is  added  to  this  when  the  circumstances  allow  and 
either  the  white  or  the  whole  egg  is  used,  according  to  the  digestive 
capacity  of  the  child. 

Such  a  diet  meets  all  the  demands  of  the  child  confined  to  bed, 
and  its  advantages  are,  that  it  can  be  further  modified  at  a  moment's 
notice,  the  proteid  is  high  enough  for  the  inactive  child  and  low 
enough  not  to  overtax  the  digestive  capacity  of  the  intestine,  water 
is  supplied  in  considerable  amount  and  helps  the  eliminative  action 
of  the  skin,  bowel,  and  kidneys ;  in  short,  it  supplies  the  necessary 
energy  with  the  minimum  tax  upon  the  digestive  and  eliminative 
forces. 


92  POST-OPERATIVE  CARE 

Other  articles  of  diet  are  added  as  soon  as  indicated,  but  always 
with  the  digestive  capacity  in  mind. 

The  Bowel  Function. — There  is  scarcely  any  need  of  emphasizing 
the  great  importance  of  regular  and  adequate  bowel  evacuations  in 
surgical  convalescence.  We  must,  however,  speak  particularly  of 
adequate  evacuations.  Time  and  time  again  we  have  proved  that, 
with  the  occurrence  of  one  or  more  evacuations  from  the  bowel  and 
even  after  the  administration  of  a  cathartic,  the  evacuations  are  not 
adequate.  This  has  been  proven  by  the  X-ray,  through  which  method 
of  examination  we  have  observed  that  a  portion  of  the  bowel  is 
full.  This  has  suggested  to  us  the  desirability  of  having  the  food 


FIG.  38. — CHILD  NEGLECTED  AFTER  OPERATION. 

When  left  even  for  a  few  moments  there  is  danger  of  injury  from  falling,  from  exposure 
and  from  the  vomitus  which  may  be  aspired. 

that  is  given  to  the  convalescent  child  weighed  and  the  probable 
residue  which  will  appear  in  the  intestines  estimated  and  this  result 
checked  off  subsequently  by  having  the  stools  weighed.  While  this  is 
in  no  manner  brought  forward  as  being  absolutely  accurate,  yet  it 
does  not  allow  of  the  intestines  'becoming  clogged  and  massed  with 
a  large  amount  of  feces  without  detection.  The  instances  in  which 
this  method  has  been  followed  have  proven  its  very  practical  value. 

It  is  necessary,  therefore,  that  the  surgeon  assure  himself  that 
there  are  not  alone  regular  evacuations  from  the  bowel  but  that  such 
evacuation  is  adequate. 

Distention  occurs  in  moderate  degree  after  practically  every  opera- 
tive procedure,  because  the  general  shock,  even  though  almost  undis- 


CAKE    OF    THE    WOUND  93 

coverable  temporarily,  involves  the  digestive  tract.  Fermentation 
is  the  result  and  may  be  only  sufficient  to  add  discomfort  to  the 
patient  or  may  become  extreme  enough  to  demand  active  interfer- 
ence. Carminatives,  change  of  posture,  massage  of  the  abdomen,  or 
enemas,  or  a  combination  of  two  or  more  of  these  usually  give  the 
desired  relief  quickly. 

But  in  paralytic  distention  we  have  a  serious  condition  and 
reliance  cannot  be  placed  upon  the  ordinary  methods  of  relief.  As 
purgation  by  the  mouth  is  usually  ineffectual,  no  time  should  be 
lost  in  dependence  upon  that  method,  but  immediate  recourse  must 
be  taken  to  irritative  enemas,  as  turpentine  and  soapsuds,  milk  and 
molasses,  or  hot  glycerin.  These  empty  the  lower  bowel  and  en- 
courage the  passage  of  gas  from  the  upper.  The  tube  through  which 
these  are  given  may  be  left  in  place,  so  that  the  further  passage  of 
gases  may  be  facilitated. 

If  repeated  enemas  are  required,  they  may  be  given  through  the 
same  tube  while  peristalsis  is  favored  by  external  applications.  But 
great  caution  must  be  exercised  that  the  skin  of  the  abdomen  is  not 
burned,  because  in  this  condition  the  abdominal  wall  becomes  more 
or  less  insensitive. 

Vomiting. — It  should  be  remembered  that  vomiting  following 
an  operation  may  be  due  to  other  causes  than  the  anesthetic,  and 
therefore  the  surgeon  as  well  as  the  anesthetist  should  be  watchful  for 
such  vomiting  as  evidence  of  intestinal  obstruction  or  peritonitis,  or 
as  an  early  symptom  of  some  acute  systemic  infection,  particularly 
uremia  or  pneumonia. 

Care  of  the  Wound. — In  children,  all  tissues  tend  to  heal  more 
rapidly  than  in  adults.  Irrespective  of  this,  there  are  certain  factors 
which  favor  rapid  healing,  as  asepsis,  a  rich  blood  and  lymphatic 
supply,  the  absence  of  tension,  and  individual  tendencies.  Two  to 
four  days  is  the  average  for  the  healing  of  skin  wounds  in  children, 
while  the  deeper  structures  require  somewhat  longer  periods,  as  from 
five  to  ten  days.  However,  it  is  much  longer  than  this  before  any 
strain  can  be  safely  placed  upon  the  parts. 

Time  for  Dressing. — If  a  wound  is  clean,  the  tendency  is  toward 
healing  by  first  intention  and  therefore  the  usual  dressing  does  not 


94  POST-OPERATIVE  CARE 

need  removal  until  it  is  time  for  the  removal  of  the  stitches.  Still, 
suppuration  may  take  place  when  least  expected  and  should  be  de- 
tected at  the  earliest  possible  moment.  It  is  not  necessary  to  remove 
the  dressing  to  determine  this,  but  the  temperature  chart,  which  is  a 
valuable  guide,  should  be  closely  watched,  and  if  it  fails  to  reach 
the  normal  after  the  first  seventy-two  hours  (during  which  time  there 
has  usually  occurred  a  slight  reaction  rise  of  temperature)  or,  hav- 
ing been  normal,  begins  to  rise,  the  wound  must  be  examined.  In 
children,  the  redressing  and  the  removal  of  stitches  is  usually  done 
on  the  fifth  day. 

The  next  dressing  is  removed  on  the  eighth  day  and  the  deeper 
sutures,  if  any,  may  be  removed  at  this  time  also. 

Care  against  Infection. — In  dressing  the  wounds,  110  irrigation 
should  be  used  and  just  as  much  care  must  be  used  in  the  preparation 
of  the  hands,  the  instruments,  and  dressings  as  in  the  original 
procedure. 

Of  course,  infection  of  the  wound  may  exist  without  fever,  but 
when  that  occurs,  there  is  the  presence  of  pain  in  the  part  which 
is  due  to  slight  swelling  and  which  is  in  no  way  associated  with 
the  initial  pain,  which  is  present  for  about  twenty-four  hours  after 
the  infliction  of  the  wound.  Thus,  pain  delayed  until  the  second 
or  third  day  should  arouse  the  suspicion  of  possible  infection,  and 
when  associated  with  fever  the  suspicion  becomes  practically  a  cer- 
tainty. 

Clinically  infection  is  designated  as  early  or  late,  although  there 
does  not  seem  to  be  any  good  reason  for  this  distinction,  for  the 
so-called  early  infection,  occurring  between  the  third  and  sixth  days, 
is  a  superficial  infection,  while  the  so-called  late  infection,  occurring 
during  the  second  week,  is  a  deep-seated  affair.  Treatment  of 
either  type  should  not  be  delayed,  but  free  drainage  must  be  estab- 
lished at  once;  it  is  absolutely  useless  to  wait  and  depend  upon 
Nature. 

Whenever  infection  occurs,  there  is  always  the  danger  of  its 
spread,  and  if  the  secretions  of  the  wound  are  allowed  free  exit  this 
danger  is  minimized.  But  despite  this,  the  virulence  of  the  germs 
may  be  such  that  the  surrounding  tissues  are  involved  or  adjacent 


THIRST:    ITS    SIGNIFICANCE    AND    RELIEF  95 

parts  infected.  The  infection  spreads  along  the  lines  of  least  re- 
sistance, so  that,  while  it  is  following  a  particular  course,  anatomic 
barriers  may  send  it  along  new  channels.  Early  and  adequate  inci- 
sions are  absolutely  necessary  for  control. 

Clean  wounds  in  infected  areas  are  treated  by  drainage  and  the 
hastening  of  the  separation  of  any  sloughing  tissues  with  incisions 
that  are  sufficiently  deep  and  long  to  accomplish  their  purpose  of 
reaching  all  parts. 

Sluggish  granulation  may  require  stimulating  applications  or 
curetting,  while  exuberant  granulations  will  need  removal. 

The  more  serious  of  the  wound  complications  are  discussed  in 
other  sections  of  this  work,  and  to  these  the  reader  is  referred. 

CHAPTER  XVI 

THIEST:    ITS  SIGNIFICANCE  AND  BELIEF 

Thirst  is  present  to  some  degree  in  every  instance  in  which  a 
child  is  subjected  to  operation.  As  its  manifestations  are  not  as 
pronounced  as  in  adults,  its  existence  may  be  overlooked.  No  doubt 
part  of  the  sensation  is  directly  due  to  the  dryness  of  the  mouth  and 
fauces  which  invariably  follows  the  administration  of  a  general 
anesthetic.  And  added  to  this  may  be  the  influence  of  the  abstrac- 
tion of  fluids  from  the  body  by  the  administration  of  active  cathartics 
preparatory  to  the  operation  or  by  vomiting,  sweating,  or  hemor- 
rhage during  or  immediately  after  the  operative  procedure. 

But  irrespective  of  these,  we  have  commonly  observed  that  op- 
erations performed  under  local  anesthesia  are  just  as  surely  followed 
by  thirst  as  when  the  general  anesthesia  is  used,  although  it  is  some- 
times of  a  slightly  lesser  degree.  The  chief  element  in  its  causation 
is  undoubtedly  the  shock  which  the  child  experiences  from  any  surgi- 
cal interference. 

The  relief  of  this  troublesome  condition  may  be  secured  in  sev- 
eral ways:  (1)  by  drinks,  (2)  washing  of  the  mouth,  (3)  adminis- 
tration cf  water  subcutaneously,  or  (4)  by  leaving  fluids  somewhere 
in  the  body  where  absorption  may  take  place  readily. 


96  THIKST:    ITS  SIGNIFICANCE  AND  RELIEF 

It  is  rarely  that  the  administration  of  very  small  quantities  of 
water  for  the  first  hour  or  two  after  an  anesthetic  and  the  giving  of 
much  larger  quantities  later  are  contraindicated  in  children.  Even 
when  the  water  is  expelled  by  vomiting  once  or  twice  it  is  serving 
a  useful  purpose  in  washing  out  the  stomach,  and,  if  retained  even  for 
a  few  minutes  in  the  child's  stomach,  some  of  the  water  is  absorbed. 
We  should  not  wait  until  the  child  complains  of  the  sensation  of 
thirst,  because  if  we  do  an  indefinite  period  may  elapse.  Children 
do  not  readily  complain  of  such  discomfort  and  it  is  not  uncommon 
to  find  them  almost  parched  from  thirst  without  any  request  being 
made  for  a  drink.  The  surgeon  must  leave  definite  instructions, 
both  as  to  the  amount  of  fluid  to  be  given  and  as  to  the  time  of  the 
administration.  These  instructions  will  depend  naturally  upon  the 
age  and  size  of  the  child,  the  nature  of  the  operative  procedure,  the 
duration  of  the  anesthesia,  and  the  degree  of  hemorrhage  and  shock 
present. 

Washing  of  the  mouth  is  most  effective  in  the  relief  of  thirst, 
and  if  used  early  and  often  there  is  rarely  any  later  suffering  from 
thirst,  but  the  child  commonly  gives  evidence  of  its  comfort  from 
the  procedure.  Any  mild  alkaline  antiseptic  fluid  may  be  used  (if 
it  contains  no  poison)  and  there  is  a  decided  advantage  in  using  it 
cool  but  not  cold.  Saline  infusion  may  be  necessary  in  some  few 
instances  and  for  this  procedure  the  same  methods  are  used  as  in 
adult  cases,  except  that  a  smaller  needle  than  usual  should  be  used. 

This  method,  however,  rarely  becomes  necessary,  if  the  surgeon 
takes  advantage  of  the  less  dangerous  and  equally  effective  one  of 
early  proctoclysis. 

Proctoclysis  has  failed  in  many  instances  to  bring  relief,  not  be- 
cause the  method  itself  is  at  fault  but  because  the  time  of  its  admin- 
istration has  been  unduly  delayed.  Early  proctoclysis  is  the  only 
effectual  proctoclysis  in  children.  The  positive  need  of  the  child 
should  be  anticipated  and  a  rectal  enema  of  eight  to  sixteen  ounces 
of  a  normal  salt  solution  (approximately  one  dram  to  the  pint)  should 
be  administered  at  the  close  of  the  operation,  or  just  as  soon  as  the 
child  is  returned  to  its  bed. 

When  it  is  appreciated  that  the  need  will  be  great,  this  may 


PAIN    AND    SLEEP  !>7 

well  be  repeated  within  one  or  two  hours.  Naturally,  all  of  this  will 
not  be  retained  but  usually  there  is  enough  tJiat  is  retained  to  be  very 
efficient  in  the  relief  of  subsequent  thirst. 

In  cases  of  urgent  demand,  where  retention  by  ordinary  procto- 
clysis  is  not  sufficient,  we  may  have  recourse  to  the  "drop"  or  "Mur- 
phy" method.  Several  forms  of  apparatus  have  been  devised  to  ac- 
complish the  purpose,  each  one  having  features  which  are  of  apparent 
advantage.  In  hospital  practice  it  is  usually  possible  to  secure  some 
such  apparatus,  but  in  private  work  advantage  has  to  be  taken  of  what 
the  home  affords.  Therefore  the  simplest  method  is  to  use  a  fountain 
syringe  with  a  tube  which  is  just  long  enough  to  reach  the  patient's 
buttocks  and  still  allow  of  some  little  play,  and  have  attached  to 
the  tube  a  small  glass  catheter.  Our  own  custom  has  been  to  use 
the  smallest  catheter  obtainable,  so  that  local  irritation  may  be 
minimized.  A  hemostat  is  then  clamped  upon  the  tubing  so  that 
the  water  escapes  at  about  the  rate  of  one  drop  a  second.  If  the 
catheter  is  introduced  from  three  to  five  inches  within  the  sphincter 
and  secured  there  so  that  there  is  little  or  no  motion  of  it,  it  may  be 
retained  indefinitely. 

We  have  demonstrated  that  wrapping  the  rubber  tubing  of  the 
fountain  syringe  with  strips  of  newspaper  cut  one  to  one  and  one- 
half  inches  wide  and  the  ends  of  each  strip  fastened  with  paste,  has 
assured  us  of  having  the  fluid  delivered  within  the  rectum  at  prac- 
tically the  same  temperature  as  it  is  within  the  bag.  This  simple 
procedure  overcomes  one  of  the  chief  causes  of  non-retention  of  the 
saline,  namely,  chilling  of  the  water  in  its  slow  passage  through  the 
tubing.  Leaving  a  considerable  amount  of  fluid  in  the  body  is 
possible  in  some  operative  procedures,  and  whenever  practical  this 
should  be  done.  It  goes  a  long  way  toward  securing  freedom  from 
subsequent  thirst  and  discomfort. 

f 

CHAPTER  XVII 

PAIN  AND  SLEEP 

There  is  such  a  close  relationship  between  post-operative  pain  and 
sleeplessness  that  the  two  might  well  be  considered  together.  It 


98  PAIN  AND  SLEEP 

must  be  clearly  appreciated  by  the  surgeon  that  in  children  the  degree 
of  post-operative  pain -bears  no  relation  to  the  extent  or  seriousness 
of  the  procedure  itself.  There  are  very  marked  differences  in  in- 
dividual children  in  regard  to  the  perception  of  pain  and  in  addition 
to  this  there  are  nutritional  factors  which  determine  very  largely  the 
degree  of  pain.  We  can  reasonably  say  that  there  is  no  one  factor  that 
has  a  more  marked  influence  over  the  existence  or  modification  of 
pain  than  the  state  of  the  child's  nutrition. 

We  need  not  expect  much  complaint  in  regard  to  post-operative 
pain  in  children  but  must  look  for  its  evidences.  As  a  rule,  chil- 
dren do  not  make  complaint  of  pain,  but  quickly  show  evidences  of 
its  effect  upon  their  general  condition.  Lacking  the  habit  of  morbid 
introspection,  these  little  ones  are  incapable  of  exaggerating  their 
ills  for  the  sake  of  attracting  attention  to  themselves,  but,  on  the 
other  hand,  they  stand  pain  so  badly  that  the  evidences  of  its  in- 
roads are  quickly  observed  and  it  is  for  these  that  the  surgeon  must 
watch.  There  is  one  thing  certain  that  discomfort  in  the  child  is 
never  exaggerated  into  the  semblance  of  pain,  as  is  so  commonly 
the  case  with  adults. 

To  avoid  unnecessary  repetition  the  reader  is  referred  to  the 
section  on  Pain  (see  page  26). 

As  rest  and  sleep  are  not  possible  with  pain  and  yet  the  two 
former  are  absolutely  essential  in  the  securing  of  a  speedy  and  safe 
convalescence,  the  element  of  pain  should  be  eliminated  as  much  as 
possible  and  the  inducing  of  rest  and  sleep  secured. 

In  the  elimination  of  pain,  foresight  is  much  better  than  hind- 
sight. There  are  many  details  in  regard  to  the  handling  of  the 
patient,  the  dressing  of  the  wound,  the  application  of  possible  splints, 
the  change  of  posture,  and  so  forth,  that,  if  neglected,  are  certain 
to  be  productive  of  post-operative  distress.  But  irrespective  of  these 
details  there  are  instances  in  which  we  are  reasonably  .certain  that 
considerable  pain  will  be  present  and  in  such  instances  it  is  our 
duty  to  anticipate  it  by  the  use  of  some  agent  to  minimize  it.  Thus, 
for  instance,  a  very  small  dose  of  a  sedative,  or  particularly  of  an 
opiate  hypodermically  just  at  the  close  of  the  operation,  is  most 
effective  in  the  relief  of  pain  and  the  securing  of  rest  and  sleep. 


POST-OPERATIVE    CONVALESCENCE  99 

Whether  to  use  morphia  in  operations  upon  the  abdomen  or  not 
is  a  question  which  has  strong  advocates  upon  both  sides.  Some 
claim  that  its  effect  is  to  exaggerate  intestinal  paresis  and  allow 
further  abdominal  distention,  thus  favoring  the  occurrence  of  peri- 
tonitis, while  others  are  certain  that  the  relief  given  more  than  war- 
rants its  use.  We  have  settled  this  discussion  for  ourselves  by  its 
administration  in  very  small  doses  and  combined  with  atropin. 
Whenever  possible  it  is  advisable  to  use  anodynes  locally. 


CHAPTEE  XVIII 

THE  GENEEAL  MANAGEMENT  OF  POST-OPERATIVE  CONVALESCENCE 

There  are  three  classes  of  children  that  come  to  the  surgeon. 
First,  there  are  those  who  have  a  surgical  condition  which  has 
more  or  less  seriously  interfered  with  their  general  health.  Second, 
there  are  those  who  present  a  surgical  condition  which  has  had  little 
or  no  effect  upon  their  general  constitutional  condition  and  who,  if 
it  was  not  for  the  surgical  condition,  might  be  considered  normal 
children.  Thirdly,  there  are  those  who,  irrespective  of  the  influence 
(or  lack  of  it)  which  the  surgical  condition  has  had  upon  their 
general  condition,  still  show  unmistakable  signs  of  a  nutritional 
fault,  which  may  or  may  not  have  been  exaggerated  by  their  inter- 
current  disease  or  condition,  but  which  becomes  an  important  factor 
when  surgical  interference  is  considered. 

We  may  well  dismiss  any  consideration  of  the  second  class  be- 
cause the  surgical  procedure  for  their  relief  is  not  interwoven  with 
any  problems  which  deal  with  a  constitutional  depression.  Surgical 
relief  is  all  that  they  require  to  restore  them  to  a  normal  state. 
Therefore  in  them  the  problems  of  convalescence  are  merely  those 
of  ordinary  hygienic  surroundings,  diet,  and  care. 

In  the  first  class  there  is  also  a  similar  proposition  because  we 
are  aware  that  as  the  surgical  condition  is  in  large  measure  or 
wholly  responsible  for  the  constitutional  symptoms,  its  relief  will 
bring  about  the  relief  of  the  latter.  However,  we  must  not  be  con- 


100  POST-OPERATIVE  CONVALESCENCE 

tent  to  restore  this  balance  of  health  by  merely  eliminating  the 
surgical  cause,  but  should  hasten  convalescence  by  all  suitable  meas- 
ures. 

Here,  then,  is  the  opportunity  for  the  administration  of  well- 
selected  stimulants  or  tonics.  Of  these,  the  best  are  cod  liver  oil, 
iron,  arsenic,  strychnin,  and  alcohol.  Cod  liver  oil  stands  clearly 
at  the  head  of  the  list  of  tonics  for  young  children,  and  this  is  em- 
phasized more  particularly  during  a  period  of  convalescence.  If  the 
precautions  are  observed  of  withholding  its  administration  during 
the  time  that  the  tongue  is  coated,  the  digestion  is  disturbed  or  the 
inclination  to  vomiting  or  nausea  exists,  its  value  will  be  soon 
evidenced. 

Most  children  are  the  subjects  either  of  anemia  or  a  faulty  nutri- 
tion, and  this  is  one  reason  why  the  oil  is  indicated  and  proves  so 
markedly  beneficial.  Iron  is  not  nearly  so  satisfactory  in  most 
cases  of  anemia  because  the  preparations  are  far  from  satisfactory, 
and  even  though  the  condition  of  the  blood  is  improved,  the  nutrition 
is  usually  not  markedly  improved. 

Arsenic  is  second  to  iron  in  its  effect  upon  anemic  conditions 
and  in  many  instances  is  much  preferable  to  iron  on  account  of 
having  no  constipating  effect. 

Alcohol  has  a  distinct  use  as  a  tonic,  particularly  during  and 
after  an  infection,  although  its  administration  must  be  in  small 
doses  and  in  combination  with  other  tonics,  whose  properties  it  en- 
hances. 

Fresh  Air  and  Sunshine.  — Every  child  needs  fresh  air  and  sun- 
shine just  as  much  as  it  needs  fresh,  pure  food,  and  it  should  be 
given  to  them  just  as  regularly  and  persistently  as  their  meals. 
Every  surgical  convalescence  is  influenced  to  some  degree  by  the 
amount  of  fresh  air  and  sunshine  supplied  to  the  patient,  and  in 
many  instances  it  is  of  prime  importance. 

The  matter  of  fresh  air  and  sunshine  in  the  treatment  of  the 
surgical  aspects  of  tuberculous  bone  disease  has  been  amply  empha- 
sized and  it  has  become  a  most  important  part  of  the  management. 
This  is  as  it  should  be,  but,  in  the  emphasis  which  has  been  placed 
upon  it,  we  have  often  overlooked  the  fact  that  similar  care  is  equally 


GAVAGE  101 

beneficial  in  all  surgical  conditions  in  children,  although  not  always 
as  insistently  essential. 

Of  course,  we  must  be  cautious  in  our  application  of  these  meas- 
ures and  safeguard  the  child  against  any  possible  dangers  from 
exposure  in  kidney  disease.  With  care  and  forethought,  it  is  prac- 
tically always  possible  to  secure  for  the  convalescent  surgical  child 
an  abundance  of  fresh  air  and  sunshine  without  exposure  that  ma\ 
prove  harmful,  and  therefore  it  is  always  indicated. 


CHAPTEE  XIX 

GAVAGE,  LAVAGE,  AND  KECTAL  FEEDING 

Gavage,  lavage,  and  rectal  feeding  are  procedures  which  are  noi 
always  familiar  to  the  surgeon.  Under  some  surgical  circumstances, 
however,  their  importance  becomes  so  great  that  a  brief  considera- 
tion of  their  application  and  uses  may  be  useful. 

Gavage.  — This  consists  of  the  forced  introduction  of  food  into  the 
stomach  through  a  tube  introduced  through  the  mouth.  The  appara- 
tus employed  is  not  complicated.  To  the  neck  of  a  glass  funnel  which 
has  a  capacity  of  from  four  to  eight  ounces  is  attached  a  piece  of 
rubber  tubing  two  feet  in  length.  To  the  end  of  this  tubing  is 
attached  a  piece  of  glass  tubing  three  to  six  inches  long  and  to  the 
other  end  of  the  glass  tube  is  attached  a  soft  rubber  catheter  with 
a  large  eye.  The  size  of  the  catheter  should  be  about  No.  16,  Ameri- 
can scale. 

When  ready  for  introduction  the  child  should  be  placed  upon 
the  back  and  its  head  held  firmly  by  an  assistant.  In  children  over 
two  or  three  years  of  age  it  is  often  necessary  to  first  introduce  a 
mouth  gag.  The  tongue  is  then  depressed  by  the  forefinger  and 
the  catheter,  which  has  been  previously  moistened  (or  lubricated  with 
glycerin),  is  passed  rapidly  back  into  the  pharynx  and  then  down 
the  esophagus.  The  rapidity  with  which  the  tube  is  passed  over  the 
pharyngeal  wall  will  determine  the  amount  of  gagging  and  struggling 
of  the  child,  for,  after  having  once  reached  the  esophagus,  it  is  rare 

L  i  U  l\  .-s  l\  \  .  C 


102 


GAVAGE,  LAVAGE,  AND  RECTAL  FEEDING 


to  encounter  any  resistance.  Usually  about  ten  inches  of  the  catheter 
are  passed  within  the  lips  and  when  that  much  has  been  accomplished 
the  funnel  should  be  raised  to  allow  the  escape  of  gas.  We  believe  it 
is  always  advisable  to  then  lower  the  funnel  so  that  any  fluid  con- 
tent of  the  stomach  may  be  siphoned  off  before  the  food  is  introduced. 
The  nourishment  selected  is  then  poured  into  the  funnel  and  this 
is  raised  slightly  above  the  level  of  the  child  so  that  the  inflow  is 
steady  but  not  forcible.  Just  as  soon  as  the  food  has  disappeared, 
the  tubing  is  pinched  and  held  firmly  while  it  is  quickly  withdrawn 


FIG.  3Q.  —  APPARATUS  FOR  STOMACH  WASHING. 
(Description  in  the  text.) 

and  by  this  method  we  prevent  any  of  the  food  from  getting  into 
the  pharynx  and  exciting  vomiting  or  coughing. 

It  is  just  as  well  to  be  in  no  haste  in  removing  the  gag  if  one  has 
been  used,  and,  if  not,  then  it  is  advisable  to  keep  the  jaws  of  the 
child  separated  by  the  finger  for  a  few  moments  to  prevent  further 
gagging.  If  any  regurgitation  of  the  food  is  to  occur  it  will  usually 
do  so  at  once  and  under  such  circumstances  it  is  advisable  to  imme- 
diately repeat  the  procedure.  For  several  minutes  after  the  feeding 
the  child  should  be  kept  quiet  upon  its  back. 


GAVAGE  103 

The  food  given  should  be  at  least  partly  predigested.  The  whole 
procedure  is  entirely  free  from  danger  and  may  readily  be  taught  to 
a  competent  attendant. 

The  advisability  or  necessity  of  this  procedure  may  arise  in  cases 
of  prolonged  vomiting  after  an  anesthetic,  when  the  child  does  not 
retain  any  food  taken  in  the  ordinary  way.  Its  usefulness  is  at 
once  apparent  in  conditions  in  which  the  child  cannot  or  will  not 


FIG.  40. — LAVAGE  IN  THE   OLDER  CHILD. 

In  younger  children  (infants)  there  is  no  need  of  the  gag  and  the  dorsal  position 
may  be  used. 

partake  of  sufficient  food  and  this  applies  particularly  to  fracture  of 
the  jaw  or  injuries  or  operative  procedures  about  the  mouth  and 
following  tracheotomy,  intubation,  and  so  forth.  The  method  is  one 
that  is  much  less  distressing  and  much  more  productive  of  good 
in  those  occasional  instances  in  which  it  becomes  necessary  to  force 
the  child  to  partake  of  food  sufficient  for  its  needs.  Its  usefulness, 
however,  is  not  strictly  limited  to  the  giving  of  food,  because  medica- 
ation  and  stimulation  may  be  administered  in  a  similar  manner. 


104     GAVAGE,  LAVAGE,  AND  RECTAL  FEEDING 

Nasal  feeding  is  similar  to  gavage  except  that  the  tube  is  intro- 
duced through  the  nose  instead  of  the  mouth.  A  much  smaller  -tube 
is  therefore  necessary  and  the  best  size  is  the  No.  10,  American 
scale.  Its  use  is  chiefly  in  those  conditions  in  which  passage  through 
the  mouth  is  inadvisable  and  when  the  use  of  a  gag  in  older  children 
would  excite  too  much  fear  and  struggling. 

Lavage. — Lavage,  or  stomach  washing,  is  accomplished  with  the 
same  apparatus  as  has  been  described  under  gavage.  However, 
instead  of  having  the  child  lying  upon  the  back  as  in  gavage,  it 
should  be  held  in  the  sitting  position  and  well  protected  with  an 
apron.  A  large  basin  should  be  provided  to  receive  the  washings 
from  the  stomach.  After  the  contents  of  the  stomach  have  been 
allowed  to  escape  as  described  under  gavage,  the  funnel  is  again 
raised  and  from  two  to  six  ounces  of  water,  containing  from  20  to  60 
grains  of  bicarbonate  of  soda,  are  introduced  and  immediately  allowed 
to  siphon  out.  The  procedure  is  then  continued  with  plain  boiled 
water  until  one  of  the  washings  returns  clear,  and  this  is  usually 
accomplished  after  about  one  quart  of  fluid  has  been  used.  The 
temperature  of  the  introduced  fluid  should  be  close  to  105°  F.,  but 
if  gastric  irritation  is  very  great,  then  this  may  be  raised  to  110° 
or  112°  F. 

Under  eighteen  months  this  procedure  is  a  most  simple  one,  but 
as  the  child  gets  older  there  is  more  and  more  fear  and  rebellion 
against  the  procedure,  so  that  it  is  often  a  very  discomforting  pro- 
cedure in  children  over  the  age  of  three  years.  In  cases  of  poisoning 
washing  is  very  valuable.  In  the  persistent  vomiting  occasionally 
seen  after  anesthesia,  lavage  alone,  or  in  combination  with  gavage,  is 
most  valuable  in  controlling  the  vomiting  and  supplying  the  needed 
amount  of  water  or  nutrition.  As  a  post-operative  measure  it  is' 
advisable  to  always  leave  an  ounce  or  two  of  the  water  in  the  stomach 
to  relieve  excessive  thirst. 

Rectal  Feeding.  — This  method  of  feeding  occupies  in  older  chil- 
dren about  the  same  field  as  it  does  in  adults.  But  in  infants  or 
very  young  children  its  application  is  very  limited.  After  a  very 
few  attempts  at  such  feedings,  the  rectum  becomes  intolerant  and 
it  has  been  our  experience  that  no  more  than  two  or  three  such  at- 


RECTAL    FEEDING 


105 


tempts  can  be  made  without  causing  trouble.  The  quantity  of  the 
injected  nourishment  must  of  necessity  be  small,  usually  not  more 
than  two  or  two  and  one-half  ounces,  and  the  interval  must  be  from 
four  to  six  hours  or  even  longer.  Peptonized  milk,  peptonoids 
(especially  the  dry  form  in  peptonized  milk),  or  other  forms  of  beef 
peptones  may  be  used. 

In  older  children  four  to  six  ounces  may  be  given  at  a  time,  and 
the  selection  of  the  nutrient  to  be 
given  has  a  wider  range.  Egg- 
albumen,  raw  beef  juice,  emulsi- 
fied fats,  a  10  to  20  per  cent, 
solution  of  raw  glucose,  or  any  of 
the  things  mentioned  as  useful  in 
infants  may  be  used.  The  ab- 
sorption of  all  of  these  is  hast- 
ened and  made  more  certain  by 
the  addition  of  1  per  cent,  of 
salt.  The  commercially  prepared 
nutrient  suppositories  may  be  ser- 
viceable. The  technique  of  ad- 
ministration is  simple.  If  possi- 
ble the  child  is  placed  upon  his 
side  in  an  exaggerated  Sim's  po- 
sition (left  sided),  or  if  this  is 
impractical  he  may  lie  upon  his 
back.  The  buttocks  are  then 

slightly    elevated.       A    long,    soft     FIG.  41. — APPARATUS  FOR  RECTAL  WASH- 
,    ,        ,  ING   OR   RECTAL   FEEDING. 

rubber  rectal  tube  is  then  intro- 
duced (or  a  large-sized  catheter),  after  lubrication  with  oil  (glycerin 
is  too  irritating).  A  funnel  which  has  been  attached  to  the  other 
end  of  the  tube  or  catheter  is  then  filled  with  the  nutrient,  and  this 
is  allowed  to  pass  very  slowly  through  the  tube,  which  should  be  about 
six  to  eight  inches  within  the  sphincter.  The  elevation  of  the  fun- 
nel should  not  be  more  than  just  sufficient  to  force  the  fluid  into  the 
rectum  slowly.  As  the  tube  is  withdrawn  the  buttocks  should  be 
held  somewhat  firmly  together  and  the  child  constrained  to  lie 


106  SHOCK 

quietly  for  from  twenty  to  thirty  minutes  or  more.     This  is  an  im- 
portant part  of  the  procedure. 

If  this  form  of  feeding  is  to  be  continued  over  a  long  period, 
daily  washings  of  the  rectum  with  some  mild  cleansing  fluid  will 
become  necessary.  Excessive  irritability  is  usually  noticed  at  first, 
and  may  often  be  controlled  by  the  addition  of  a  few  drops  of  laud- 
anum to  the  first  enemas.  Rectal  feeding  should  never  be  continued 
indefinitely ;  as  soon  as  it  is  possible  to  do  so  it  should  be  stopped. 


CHAPTER  XX 

SHOCK 

There  are  four  things  which  all  children  bear  badly :  pain,  hemor- 
rhage, starvation,  and  cold.  Therefore  the  injured  child  is  already 
subjected  to  the  influences  of  shock,  the  child  to  be  operated  upon  is 
very  liable  to  it.  While  we  possess  an  accumulated  knowledge  of 
this  condition,  a  knowledge  which  has  come  through  the  untiring 
efforts  and  studies  of  various  clinicians  and  laboratory  workers,  yet 
no  one  has  correlated  this  knowledge  in  such  a  form  as  to  make  it 
readily  available  and  understandable:  we  are  still  without  a  clear 
understanding  of  the  physiology  of  its  production,  and  therefore  of 
its  classification. 

But  we  have  in  shock  clinical  manifestations  which   are  well 
marked,  and  which  go  to  prove  that  it  is  a  complete  clinical  entity, 
made  up  of  lowered  functions,  which  make  up  the  picture  of  par- 
tially suspended  animation.     This  condition  varies  in  its  several  de- 
grees just  as  in  adult  life. 

Diagnosis. — The  diagnosis  of  shock  in  childhood  is  not  always 
easy,  for  it  may  be  slight  in  degree,  and,  as  there  is  a  difficulty  in 
clearly  describing  the  condition,  personal  experience  is  a  large  fac- 
tor in  its  early  recognition.  Eor  instance,  the  child  may  be  dazed 
and  yet  quite  conscious,  with  mental  faculties  which  act  clearly  but 
somewhat  sluggishly.  The  whole  nervous  system  seems  to  be  de- 
pressed, and  yet  the  child  exhibits  much  restlessness.  The  cutaneous 


ETIOLOGY  107 

and  the  other  reflexes  may  be  absent  or  markedly  diminished.  The 
pupils  react  slowly,  and  may  be  dilated.  There  is  a  peculiar  pale- 
ness of  the  skin  and  mucous  membranes,  and  the  face  of  the  child 
may  look  pinched.  The  skin  is  covered  with  a  cold  perspiration. 
The  respirations  are  shallow,  the  pulse  weak  and  rapid,  the  blood 
pressure  lowered,  and  the  temperature  often  subnormal. 

Now,  all  of  these  may  or  may  not  be  present.  Certain  it  is  that 
if  but  one  or  two  are  present  we  are  hardly  justified  in  calling  the 
condition  shock.  It  is  the  composite  picture,  the  blending  of  several 
of  these,  that  the  experienced  observer  recognizes  as  the  symptoms  of 
shock  in  the  child. 

Etiology. — The  causes  of  shock  are  several,  and  in  a  consideration 
of  the  subject  it  is  necessary  to  take  up  some  of  these  in  detail. 

Injury  as  the  cause  of  shock  is  influenced  in  its  importance  by 
several  factors: 

(a)  The  greater  the  injury  or  irritation  of  the  sensory  nerves  the 
greater  the  liability  to  and  the  degree  of  shock.  This  is  true  because 
of  the  delicacy  of  the  child's  tissues  and  the  fact  that  injuries  in- 
volving similar  areas  are  proportionately  more  severe  in  children 
than  in  adults. 

,  (b)  For  quite  similar  reasons  as  stated  above  the  site  of  the  in- 
jury becomes  an  important  factor,  and  if  the  injury  be  small  but 
involving  an  area  well  supplied  by  sensory  nerves  it  is  of  much  more 
consequence  in  the  production  of  an  unfavorable  effect  upon  the  vaso- 
motor  centers  than  an  injury  of  larger  extent  in  a  less  sensitive  part. 
Therefore,  in  the  production  of  shock  such  injuries  are  more  im- 
portant. 

(c)  The  kind  of  injury  is  an  important  factor  also.  It  has  been 
demonstrated  time  and  time  again,  experimentally  and  clinically,  that 
dragging  injuries  (particularly  if  directly  or  indirectly  affecting  an 
organ)  are  most  disastrous  in  their  effects.  Thus  it  will  be  seen  that 

O  / 

blunt  dissection,  tearing,  or  any  rough  manipulation  of  the  tissues 
will  invite  shock. 

If  we  were  to  place  these  in  the  order  of  their  importance  drag- 
ging injuries  would  be  placed  at  the  top  of  the  list  and  far  beyond 
any  other  in  point  of  importance.  Even  if  involving  the  most  sensi- 


108  SHOCK 

live  parts,  if  the  injury  be  extensive  but  not  of  a  crushing,  rolling, 
or  dragging  nature,  it  is  much  less  liable  to  produce  shock  in  children 
than  the  dragging  of  an  organ  or  of  its  attachments  even  if  the 
organ  itself  escape  serious  injury. 

Hemorrhage  has  always  been  recognized  as  an  important  factor 
in  the  production  of  shock,  and  this  is  of  special  force  in  children. 
Irrespective  of  the  fact  whether  the  blood  pressure  is  reduced  to 
any  considerable  degree  or  not,  the  mere  loss  of  blood  will  prove 
sufficient  in  young  children  to  bring  about  shock.  And  this  is  further 
influenced  by  the  rapidity  with  which  the  blood  is  lost,  for  if  an 
ounce  of  blood  is  extracted  rapidly  shock  is  much  more  intense  than 
if  a  similar  amount  escape  slowly. 

Exposure  to  cold  is  not  always  recognized  as  an  important  factor 
in  the  production  of  shock,  and  yet  in  childhood  its  influence  is 
large,  it  being  a  close  second  to  hemorrhage.  Such  exposure  may 
take  place  in  the  operating  room  from  an  unequal  temperature,  or 
may  follow  removal  to  the  recovery  room,  which  may  have  a  tem- 
perature which  is  very  diiferent  in  degree  from  that  of  the  operating 
room.  Not  infrequently  exposure  takes  place  while  the  patient  is 
being  removed  from  table  to  bed,  and  the  adjustment  is  not  made 
efficiently. 

Exposure  to  heat  becomes  a  factor  in  the  production  of  shock 
through  the  influence  of  burns  which  are  more  or  less  extensive,  or 
by  exhaustion  due  to  summer  heat. 

The  duration  of  the  anesthesia  often  becomes  a  factor  in  the  pro- 
duction of  shock,  for  prolonged  anesthesia  is  never  well  borne  by 
children.  The  present  fact  that  the  child  is  "taking  the  anesthetic 
well"  is  never  a  good  reason  why  its  administration  should  be  need- 
lessly prolonged,  for  the  present  in  anesthesia  does  not  foreshadow 
the  future.  It  is  not  an  uncommon  experience  to  find  that  a  child 
taking  the  anesthetic  well  suddenly  gives  evidence  of  shock.  Tnis 
may  prove  mild  or  become  alarming. 

The  duration  of  the  operation  is  somewhat  closely  allied  to  the 
duration  of  the  anesthesia,  but  not  essentially  so.  If  it  became  a 
question  of  choice  as  to  whether  to  prolong  the  anesthetic  or  hasten 
the  operation  with  its  consequent  rapid  and  therefore  necessarily  less 


TREATMENT    OF    SHOCK  109 

gentle  handling  of  the  tissues,  we  would  emphatically  advise  the 
prolongation  of  the  anesthesia. 

Fear  and  dread  of  either  the  operation  or  its  consequences  are 
of  course  entirely  absent  in  infancy,  and  many  believe  that  this  ex- 
tends well  into  the  period  of  later  childhood.  It  is  not  so.  Older 
children  have  intense  and  lively  imaginations,  and  these  have  com- 
monly been  unguided,  so  that  even  with  but  little  to  work  upon  the 
child  can  conjure  up  situations  which  are  purely  imaginary,  but 
which  are  so  real  to  the  child  as  to  result  in  shock.  Of  course  this 
factor  is  under  more  perfect  control  of  the  surgeon  than  in  adults, 
because,  with  sufficient  tact  and  judgment  the  child  can  often  be 
kept  in  entire  ignorance  of  what  may  be  impending. 

However,  to  belittle  this  factor  in  children  is  to  lose  sight  of 
something  which  it  is  well  to  keep  in  view. 

Anemia  most  certainly  conduces  to  the  production  of  shock,  and 
this  undoubtedly  comes  largely  through  the  fact  that  the  anemic 
child  is  always  muscularly  weak  and  lacks  nerve  tone.  It  is  a  factor 
which  demands  consideration,  and  a  blood  examination  would  al- 
ways give  to  the  surgeon  an  estimate  of  its  probable  influence. 

Treatment  of  Shock. — The  treatment  of  shock  resolves  itself  very 
largely  into  an  avoidance  of  those  factors  which  are  known  to  pro- 
duce it,  or,  at  least,  the  institution  of  measures  to  limit  their  in- 
fluence. 

To  some  extent  the  nature  and  extent  of  an  injury  are  beyond  the 
control  of  the  surgeon,  but,  on  the  other  hand,  when  an  operative 
procedure  is  necessary  much  may  be  done  to  limit  or  prevent  serious 
injury.  Even  in  the  apposition  of  injured  or  torn  parts  the  surgeon 
can  be  very  delicate  in  his  manipulation,  and  it  is  his  duty  to  be  so 
whether  the  child  is  under  an  anesthetic  or  not.  Unnecessary  or 
rough  handling  of  any  tissues  should  be  avoided.  And  especially 
should  dragging  or  pulling  manipulations  be  forbidden;  we  say  "for- 
bidden" because  the  active  offender  is  usually  the  surgeon's  as- 
sistant, who  is  entrusted  with  retractors  and  forceps.  It  is  necessary 
then  that  the  instruments  used  be  those  of  a  suitable  size,  and  the 
handling  done  in  such  a  manner  as  to  limit  as  much  as  possible 
injury  to  tissue,  and  especially  all  such  injury  as  results  from  pull- 


110  SHOCK 

ing.  Almost  ranking  with  the  injury  in  importance  as  a  factor  in 
shock  is  hemorrhage,  and  the  control  or  limitation  of  this  becomes 
a  very  important  element  in  the  treatment  of  shock.  To  avoid 
repetition  the  reader  is  referred  to  the  chapter  on  "Control  of  Hem- 
orrhage" (see  page  84). 

To  limit  the  dangers  from  exposure  to  cold  there  must  be  ade- 
quate protection  of  the  child  during  and  after  the  operation.  Only 
the  field  of  operation  should  be  exposed,  and  the  rest  of  the  body 
must  be  amply  covered  to  prevent  any  possibility  of  chilling  of  the 
surface.  When  the  operation  is  to  be  one  of  considerable  severity 
or  length  the  child  should  be  further  protected  by  hot  water  bottles, 
or,  in  some  instances,  a  warm  water  mattress  may  be  desirable. 
Everything  must  be  done  to  avoid  having  the  surface  remain  wet, 
and,  therefore,  there  must  be  provision  made  for  the  liberal  use  of 
hot,  dry,  sterile  towels.  The  bed  of  the  recovery  room  must  also  be 
suitably  warmed  and  the  child  protected  from  dampness. 

To  limit  the  duration  of  the  period  of  anesthesia  it  is  necessary 
to  make  provision  for  every  possible  emergency  in  addition  to  plan- 
ning the  arrangement  of  the  room,  the  instruments,  and  the  instruc- 
tion of  the  assistants  and  nurses  in  their  respective  duties. 

To  limit  the  consequences  of  undue  fear  or  dread  all  planning  in 
regard  to  the  operative  procedure  should  be  done  without  the  knowl- 
edge of  the  child. 

If  any  considerable  degree  of  anemia  is  present  (as  evidenced 
by  the  blood  examination)  the  operation  should  be  delayed,  if  it  be 
one  of  election,  until  the  percentage  of  hemoglobin  can  be  raised  to 
a  safe  and  satisfactory  standard.  There  is  no  need  of  our  advising 
that  extra  precautions  be  taken  against  exposure  to  cold  and  to 
hemorrhage,  for  we  are  strongly  convinced  that  it  is  the  clear  duty 
of  the  surgeon  to  always  give  the  strictest  attention  to  these  details, 
and  this  should  be  done  irrespective  of  whether  anemia  is  present 
or  not. 

The  further  treatment  of  shock  in  children  involves  those  meas- 
ures which  are  generally  recognized  as  efficient  in  restoring  a  normal 
equilibrium  when,  through  the  influence  of  one  or  more  of  the  causa- 
tive factors  of  shock,  this  has  once  been  disturbed.  The  dorsal 


TEEATMENT    OF    SHOCK  111 

posture,  with  the  head  low  and  the  feet  elevated,  should  be  main- 
tained, but  in  doing  so  the  most  gentle  measures  must  be  adopted 
in  restraint.  For  a  short  time  the  child's  body  may  be  placed  at  an 
angle  of  about  45  degrees.  Artificial  heat  is  usually  necessary  to 
maintain  the  normal  temperature.  The  administration  of  oxygen 
may  be  necessary,  and  is  always  desirable  when  an  anesthetic  has 
been  used. 

Small  doses  of  morphia  subcutaneously  act  remarkably  well  as 
a  sedative  and  heart  tonic,  and  allay  restlessness  and  pain  after  the 
child  has  become  conscious. 

If  the  degree  of  shock  is  great  the  limbs  may  be  bandaged  to- 
ward the  heart  with  cotton  underneath  the  roller  bandage.  The 
value  of  normal  salt  solution  is  very  great  in  some  instances,  and  its 
subcutaneous  administration  at  a  temperature  of  from  105°  to  110° 
F.  should  be  tried,  and  particularly  if  much  hemorrhage  has  taken 
place.  In  urgent  cases  the  solution  may  be  given  intravenously. 


SECTION  V 

CONSTITUTIONAL  AFFECTIONS  WITH  A  SURGICAL 

ASPECT 

CHAPTER  XXI 

HEMOPHILIA 

Hemophilia  is  a  disease  in  which  there  is  a  marked  tendency  to 
excessive  bleeding  from  the  slightest  wound,  or,  in  its  more  exag- 
gerated form,  the  hemorrhage  may  be  spontaneous.  Such  children 
are  known  as  "bleeders." 

Etiology. — The  hereditary  factor  in  the  disease  is  very  marked, 
and  it  has  been  reported  as  traced  through  six  or  seven  generations. 
The  disease  is  most  frequently  transmitted  through  the  mother,  and, 
although  transmitting  it,  she  may  remain  free  from  its  influence. 
This  is  important  to  remember  in  taking  the  history.  More  males 
are  affected  than  females,  the  proportion  being  12  to  1.  The  exact 
nature  of  the  disease  is  still  uncertain,  and  patients  affected  with  it 
show  no  other  abnormality  which  can  be  connected  with  the  disease. 
Isolated  instances  have  been  reported  where  there  was  a  complete 
failure  to  trace  a  hereditary  factor.  It  is  a  peculiar  fact  in  the 
transmission  of  the  disease  that  a  woman  herself  free  from  the  dis- 
ease, but  with  family  taint,  may  marry  a  perfectly  healthy  man  and 
her  daughters  remain  free  from  the  disease,  while  all  of  the  sons 
are  affected.  The  disease  is  more  prevalent  in  cold  than  in  warm 
climates,  and  in  certain  communities  it  seems  to  be  particularly  more 
common  (probably  on  account  of  intermarriage).  Usually  the  first 
symptoms  are  noticed  during  the  first  two  years  of  life,  and  if  the 
child  shows  no  tendency  to  it  during  the  first  eight  or  ten  years  he 
may  be  .considered  exempt. 

113 


DIAGNOSIS  113 

Pathology. — It  has  been  contended  that  there  exist  an  unusual 
thinness  of  the  walls  of  the  arteries  and  some  degenerative  changes, 
but  this  is  far  from,  proven.  The  most  that  can  be  said  is  that  the 
pathology  is  unknown. 

Symptomatology. — The  symptomatology  is  simple.  The  child 
receives  a  scratch,  abrasion,  or  slight  injury,  and  this  is  immedi- 
ately followed  by  excessive  and  sometimes  uncontrollable  hemorrhage. 
There  is  usually  no  marked  hemorrhage,  but  a  profuse  and  steady 
oozing;  and  this  may  last  for  several  days.  Sometimes  the  oozing 
may  subside  completely  for  a  few  hours  or  it  may  markedly  diminish, 
only  to  be  continued  after  a  short  time. 

In  some  instances  spontaneous  hemorrhages  take  place,  and  in 
these  cases,  in  which  direct  injury  is  not  a  factor,  there  are  very  apt 
to  be  prodromes,  such  as  a  full  feeling  in  the  head,  dizziness,  dis- 
turbances of  hearing  and  of  vision,  and  similar  indefinite  symptoms 
which  all  subside  as  the  hemorrhage  takes  place.  In  these  cases 
petechia,  hematoma,  and  ecchymoses  are  common,  and  bleeding  from 
the  mucous  surfaces  is  very  apt  to  occur.  There  are  at  times  cases 
in  which  large  effusions  of  blood  are  detected  into  the  joints,  and  this 
occurrence  may  be  accompanied  with  or  without  fever. 

The  symptoms  present  after  the  bleeding  has  stopped  are  those 
which  would  be  present  in  the  same  child  under  other  conditions  of 
severe  hemorrhage. 

Diagnosis. — The  history  of  the  case,  the  uncontrollable  hemor- 
rhage, the  character  of  the  hemorrhage,  and  the  slight  injury  which 
causes  it  are  usually  sufficient  factors  to  establish  the  diagnosis. 

Hemophilia  must  not  be  confounded  with  hemorrhagic  disease 
of  the  new-born,  which  shows  but  slight  tendency  to  predominate 
in  boys,  and  which  is  evidenced  within  the  first  days  after  birth  in 
the  form  of  multiple  hemorrhages.  If  the  infant  lives,  within  a 
few  days  any  operative  procedure  (such  as  circumcision)  may  be 
undertaken  without  unusual  hemorrhage. 

Bleeding  from  the  umbilicus  is  common  in  hemorrhagic  disease, 
but  is  very  rare  in  hemophilia. 

When  there  is  a  joint  involvement  the  case  might  be  mistaken 
for  one  of  scurvy,  when  hemophilia  is  the  real  cause  of  the  lesion. 


114  HEMOPHILIA 

The  dietetic  treatment  would  have  a  rapid  effect  in  scurvy,  but 
absolutely  none  in  hemophilia. 

Prognosis. — This  is  worse  in  males  than  in  females.  The  longer 
the  child  lives  the  better  the  prognosis,  as  the  liability  to  the  occur- 
rence of  hemorrhage  decreases  with  age. 

Treatment. — The  marriage  of  bleeders  should  be  prevented  when- 
ever possible,  and  this  is  especially  true  of  the  daughters.  In  the 
case  of  a  child  known  to  be  a  hemophiliac  every  precaution  should 
be  taken  against  the  occurrence  of  injury.  At  the  first  appearance  of 
hemorrhage,  or  the  appearance  of  prodromes,  the  child  should  be 
placed  in  bed  and  guarded  against  all  physical  and  mental  excite- 
ment. If  the  hemorrhagic  part  is  accessible  gentle  pressure  should 
be  applied.  Practically  every  known  styptic  has  been  used,  but  all 
with  about  the  same  results :  ineffectual. 

Adrenalin,  1 : 1,000,  applied  directly  to  the  hemorrhagic  point  has 
claimed  the  most  advocates  recently.  Ergot,  iron,  and  cocain  all  have 
their  sponsors.  Gelatin  solutions  may  be  tried  by  mouth,  but  the 
subcutaneous  use  of  it  must  be  avoided,  as,  even  with  the  greatest 
caution,  tetanus  may  result,  and  the  injury  caused  by  the  needle 
opens  another  avenue  for  profuse  hemorrhage. 

The  application  of  ligatures  and  sutures  has  proven  a  failure 
because  of  the  subsequent  slough  which  is  almost  inevitable  and  the 
renewal  of  the  hemorrhage  thereby. 

It  has  long  been  recognized  that  the  serum  which  separates  from 
clotted  blood  contains  something  which  favors  coagulation  of  blood. 
This  has  led  many  investigators  to  experiment  with  various  sera, 
and  with  somewhat  widely  varying  results.  There  are  so  many 
questions  that  still  remain  unsettled,  and  there  are  so  many  factors 
of  which  we  know  little,  that  we  may  say  that  the  experimental  stage 
is  not  yet  over. 

If  it  can  be  freshly  obtained ;  that  is,  within  a  month  of  its  with- 
drawal from  the  animal,  diphtheria  antitoxin  may  be  used.  What- 
ever serum  is  used,  there  should  be  injected  about  10  to  20  c.  c.,  and 
this  may  be  repeated  several  times  if  necessary.  The  fresher  the 
serum,  however,  the  more  certain  the  result.  Fresh  rabbit  serum  is 
particularly  serviceable  because  quite  easy  to  obtain.  Leary's  method 


EACHITIS  115 

is  to  shave  the  chest  of  the  rabbit  over  the  sternum  and  left  side,  and 
with  an  ordinary  antitoxin  needle  puncture  to  the  left  of  the  sterum 
about  1  cm.  above  a  line  drawn  transversely  at  the  junction  of  the 
sternum  and  ensiform,  thrusting  the  needle  toward  the  middle  line 
and  slightly  upward.  This  punctures  the  left  ventricle  and  about  30 
c.  c.  of  blood  is  withdrawn  slowly  and  collected  in  sterile  centrifuge 
tubes.  After  a  short  period  in  the  thermostat  the  clot  is  separated 
by  a  platinum  needle,  and  the  material  shaken  in  an  electric  centri- 
fuge and  the  serum  withdrawn.  Subcutaneous  injection  is  the  pre- 
ferable method. 

More  recently  there  have  been  many  experiments  carried  on  with 
fresh  blood  withdrawn  from  some  blood  relation,  and  this  directly 
injected  into  the  patient,  and  the  results  have  seemed  to  warrant  a 
much  more  extended  trial. 

When  blood  serum  is  needed  for  any  hemorrhagic  condition  oc- 
curring during  childhood  the  most  rational  procedure  to  us  seems  to 
be  to  withdraw  the  needed  blood  from  some  healthy  member  of  the 
immediate  family,  and  to  obtain  the  serum  from  this.  The  procedure 
is  simple,  the  fresh  blood  is  always  obtainable,  and  the  chances  of 
failure  are  materially  reduced  by  such  a  procedure. 

We  have  had  splendid  results  by  this  method  in  purpura  of  the 
various  degrees. 

Direct  blood  transfusion  is  indicated  in  the  severer  cases  using 
vein  to  vein  anastomosis  if  practical. 

CHAPTER  XXII 

KACHITIS 
(Rickets) 

This  is  one  of  the  commonest  diseases  of  childhood,  and  one 
which  must  have  a  large  interest  for  the  surgeon.  Popularly  it  is 
supposed  to  exist  chiefly  among  the  poorer  classes  in  large  cities,  and 
if  we  simply  gave  attention  to  the  more  marked  manifestations  of 
the  disease  as  evidenced  by  deformity  this  would  seem,  to  be  true. 


116 


EACHITIS 


But  if  the  earlier  and  less  prominent  symptoms  of  the  disease  are 
known  and  recognized  it  will  be  found  to  exist  commonly,  even  in 
the  children  of  the  well-to-do.  This  is  all  the  more  surprising  when 
we  recall  that  few  diseases  are  so  easy  of  prevention.  This  efficacy 
of  preventive  measures  exists  despite  the  fact  that  there  are  many 
problems  in  the  etiology  of  the  disease  which  we  do  not  understand. 
The  effect  of  the  disease  upon  the  manner  in  which  the  affected 

child  responds  to  in- 
jury, infection,  or  dis- 
ease is  such  that  no 
one  who  is  treating  chil- 
dren can  overlook. 
This  influence  is  so 
great  that  one  should  be 
so  perfectly  familiar 
with  the  earliest  mani- 
festations of  the  disease 
and  the  causes  which 
lead  up  to  it  that  he  will 
not  be  misled  by  symp- 
toms of  other  diseases 
and  injuries  as  they  are 
exaggerated  or  marked- 
ly modified  by  the  pres- 
ence of  rachitis. 

Etiology. — W  h  i  1  e  , 
for   practical    purposes, 
it  may  be  assumed  that 
rickets  is  a  dietetic  dis- 
ease, there  are  many  contributing  factors  which  must  be  given  recog- 
nition.    These  contributing  factors  are : 

(a)  RACIAL. — The  disease  is. much  more  prevalent  among  the 
Italians  and  negroes  and,  irrespective  of  the  activity  of  the  cause  in 
these  races,  there  is  always  a  more  marked  type  of  the  disease.  This 
racial  susceptibility  may,  however,  be  due  to  another  factor,  namely, 
poor  hygienic  surroundings. 


FIG.  42. — SIDE  VIEW  OF  RACHITIC  BOY. 
The  enlarged  wrist  and  elbow  are  well  shown  and 
the  flabbiness  of  the  muscles  is  evidenced  by 
the  marked  flattening  of  the  buttocks.  This 
flabbiness  is  one  reason  why  the  bones  are  so 
easily  distorted  as  they  lack  muscular  protection 
and  support. 


ETIOLOGY 


117 


(b)  POOR  HYGIENIC  SURROUNDINGS. — The  varied  manifestations 
of  the  disease   are   seen  most   commonly  among   children   who   are 
poorly  housed  and  with  hygienic  surroundings  which   are  not   the 
best. 

(c)  DIGESTIVE  DISTURBANCES. — It  is   quite  evident  that  if  a 
chronic  state  of  indigestion  is  allowed  to  continue,  or  if  acute  attacks 
of  the  same  are  frequent,  no  matter  what  may  be  the  manner  of 
feeding  the  infant,  rachitis  is  almost  certain  to  be  evidenced  later  on. 


FIG.  43. — RACHITIC  DEFORMITY.      '"|        FIG.  44. — RACHITIC  DEFORMITY. 

Of  course  we  must  not  lose  sight  of  the  fact  that  digestive  disturb- 
ance is  commonly  the  accompaniment  of  rachitis. 

(d)  DIET. — The  influence  of  heredity  and  of  syphilis  as  etiologi- 
cal  factors  is  doubtful.  Of  most  importance,  however,  is  the  dietetic 
cause.  The  question  at  once  arises  as  to  what  definite  fault  in  the  diet 
causes  the  disease.  This,  we  believe,  can  be  answered  in  the  follow- 
ing way :  It  is  caused  by  a  deficiency  in  the  assimilation  of  the  fats. 

Of  all  the  diets  which  have  been  assigned  as  active  causes  of 


118  EACHITIS 

rachitis  condensed  milk  easily  takes  the  lead,  with  cow's  milk  diluted 
too  much  a  close  second,  and  patent  foods,  starch-containing  foods, 
breast  milk  combined  with  starch-containing  foods,  and  breast  milk 
alone  following  in  the  order  named.  Let  us  consider  these  more 
in  detail. 

Condensed  milk  diluted,  as  is  ordinarily  suggested,  is  rich  in 
sugar  but  very  deficient  in  fat.  The  excess  of  sugar  has  repeatedly 
been  blamed  as  the  element  at  fault,  but  this  is  disproven  by  two 
facts ;  in  those  instances  in  which  fat  is  added  to  the  mixture  in  the 
form  of  cream  (the  sugar  percentage  remaining  the  same)  rachitis 
is  not  apt  to  develop,  and  if  the  dilution  of  condensed  milk  is  greater 
than  that  ordinarily  recommended  (thus  causing  reduction  in  the 
sugar  percentage  also)  rachitis  will  quickly  develop.  In  this  instance, 
then,  it  is  not  an  excess  of  sugar,  but  a  deficiency  in  fats. 

Cow's  milk  may  be  diluted  too  much,  and  this  will  result  in  a 
reduction  of  the  fats,  proteids,  and  sugar.  But  even  with  a  dilution 
with  equal  quantities  of  water  the  fats  and  the  sugar  suffer  while 
the  proteid  still  remains  near  to  what  is  normal  in  breast  milk. 
This  would  indicate  that  the  proteid  is  not  the  element  at  fault,  and, 
as  we  have  already  mentioned  the  facts  in  regard  to  sugar,  it  would 
seem,  that  here,'too,  the  fault  is  a  fat  deficiency. 

The  patent  foods  are  rarely  used  correctly.  The  usual  method  is 
to  make  the  infant's  digestive  power  accommodate  itself  to  some  par- 
ticular formula  for  a  given  age,  and  if  it  seems  to  agree  no  further 
effort  is  made  to  determine  how  well  it  agrees.  Thus,  in  nearly 
every  instance,  we  find  that  where  a  patent  food  is  given  it  is  diluted 
too  much  for  the  individual  needs  of  the  infant,  and,  even  if  suited 
to  the  case  in  question,  the  food  is  deficient  in  fat.  It  will  be  found 
that  those  patent  foods  which  are  followed  in  the  smallest  number  of 
instances  by  rachitis  are  those  in  which  the  attempt  has  been  made  to 
bring  the  fat  element  up  to  a  higher  standard. 

Starch-containing  foods  become  factors  in  the  causation  of  ra- 
chitis in  this  manner:  they  are  given  to  the  exclusion  of  the  proper 
amounts  of  fat  in  other  food.  For  instance,  when  an  infant  is  given 
bread,  potato,  or  other  starchy  food  freely,  foods  which  contain  fat 
are  not  taken  in  sufficient  quantity  to  meet  the  demands  of  the  sys- 


ETIOLOGY 


119 


tern.  In  such  cases  starch  excess  means  fat  deficiency.  Further 
than  this,  an  infant  given  an  amount  of  starch  which  is  not  easily 
digested  soon  loses  its  power  of  assimilating  food  in  general,  and 
thus  its  diminished  intake  of  the  fats  is  exaggerated  by  the  inability 
to  digest  and  assimilate  them. 

Breast  milk  combined  with  starch-containing  foods  must  come 
under  the  same  analysis  as  the  fore- 
going (starch-containing  foods),  and 
the  fault  is  similar:  starch  excess  caus- 
ing failure  of  assimilation.  Breast 
milk  alone  as  the  diet  may  result  in 
rachitis  if  the  milk  is  poor  in  quality 
or  if  breast  feeding  is  persisted  in  until 
it  becomes  so.  In  practically  every  in- 
stance an  examination  of  the  breast  milk 
will  prove  decided  departures  from  the 
normal.  Many  times  the  mother  will 
be  found  to  be  poorly  nourished  or 
pregnant. 

We  have  sometimes  met  cases  in 
which  it  was  impossible  to  explain  satis- 
factorily the  occurrence  of  rachitis, 
either  upon  the  theory  of  fat  deficiency 
or  any  other  basis.  However,  thess 
few  instances  need  not  detract  from  the 
value  of  the  fat  deficiency  theory,  nor 
need  they  make  us  lose  sight  of  the  F  45 
practical  application  of  such  a  theory 
in  treatment :  the  giving  of  fats. 

Of  all  the  methods  used  in  con- 
trolling this  disease  authors  are  practically  a  unit  in  the  adminis- 
tration of  cod  liver  oil,  although  some  use  other  oil  as  being  mere 
easily  digested.  However,  the  principle  is  the  same:  the  administra- 
tion of  fats. 

As  was  stated  earlier  in  this  chapter,  long-continued  or  frequently 
repeated  disturbances  of  digestion  lead  to  the  development  of  ra- 


RACHITIC  DEFORMITY 
IN  CHILD  OF  FIFTEEN  MONTHS, 
WHOSE  PARENTS  NOTICED  NOTH- 
ING WRONG  EXCEPT  THAT  INFANT 
COULD  NOT  WALK. 


120 


RACHITIS 


chitis.  The  fault  which  underlies  may  be  any  one  of  the  various  fac- 
tors, and  through  its  influence  in  disturbing  the  digestion  may  result 
in  fat  deficiency  through  imperfect  assimilation. 

Not  as  uncommonly  as  supposed  the  real  cause  of  the  deficiency 
may  be  the  excess  of  fat  in  the  food.  A  very  high  fat  percentage 
in  a  food  may  cause  a  considerable  gain  in  weight  for  a  time,  but 

this  cannot  continue,  for  the  disturbances 
of  digestion  become  frequent.  Assimila- 
tion then  suffers  and  there  is  fat  deficiency. 
Rachitis  may  therefore  occur  because  of 
this  excess  of  fat. 

To  sum  up,  then,  the  dietetic  cause 
and  the  practical  application  of  treatment 
which  is  immediately  beneficial  in  its  re- 
sults are  best  explained  upon  the  theory 
of  deficiency  of  fat,  whether  that  deficiency 
is  due  directly  to  a  percentage  reduction 
of  the  fat  or  the  inability  to  assimilate  it. 
Age  Incidence.  • — This  is  very  difficult 
to  determine  because  the  disease  begins  so 
insidiously,  but  it  is  a  fact  that  has  been 
noted  repeatedly  that  evidences  of  the  dis- 
ease are  more  apt  to  appear  during  the 
second  year  than  the  first.  The  usual  time 
for  the  appearance  of  the  first  symptoms 
is  between  the  sixth  month  and  the  fif- 
teenth, and  the  later  periods  show  the 
most  cases.  This  suggests  the  value  of 
diet  in  its  prevention,  and  will  be 
taken  up  under  the  treatment. 

Symptoms. — Of  slow  development  and  insidiously  appearing,  it 
must  be  evident  that  the  first  symptoms  of  rachitis  are  difficult  of 
detection.  But,  on  the  other  hand,  the  failure  of  detection  is  fre- 
quently due  to  neglect  in  paying  heed  to  the  less  prominent  symp- 
toms. 

EARLY  SYMPTOMS. — Anemia  is  the  most  constant  early  symptom 


FIG.  46. — COMPARATIVE  CON- 
TOURS OF  THE  NORMAL 
(UPPER  FIGURE)  AND  THE 
RACHITIC  (LOWER  FIGURE) 
STOMACH. 

These  figures  were  drawn  after 
the  stomach  had. been  out- 
lined and  are  a  composite 
outline  of  the  stomachs  of 
twenty  normal  and  twenty 
rachitic  infants  of  practi- 
cally the  same  ages. 


SYMPTOMS  121 

of  rachitis,  and  if  it  is  evidenced  in  an  infant  who  is  apparently 
otherwise  well  nourished  it  should  excite  our  attention.  There  is 
nothing  which  may  be  considered  as  characteristic  about  this  anemia, 
for  there  is  the  usual  symptomatology,  and  examination  of  the  blood 
shows  the  usual  findings  of  an  anemia. 

Associated  with  the  anemia  there  is  a  muscular  flabbiness  which 
is  usually  marked.  The  infant  may  appear  to  be  well  nourished 
and  fat,  but  there  is  no  effort  made  to  make  a  good  healthy  use  of 
muscles  which  are  apparently  well  developed.  The  head  will  not  be 
held  up  firmly,  the  musculature  of  the  back  is  weak,  the  little  one 
may  not  attempt  to  sit  up,  or  it  may  do  so  unsteadily  and  exhibit  all 
the  signs  of  muscular  weakness. 

Constipation  is  the  rule  because  of  muscular  atony  associated 
with  a  faulty  diet.  The  general  muscular  flabbiness  may  also  be 
demonstrated  by  palpation.  The  poorly  nourished  skin  becomes  soft 
and  easily  irritated.  Sweating  about  the  head,  particularly  when 
the  infant  makes  the  effort  of  nursing  and  during  sleep,  is  an  early 
accompaniment  of  anemia.  This  sweating  may  be  the  first  symptom 
to  indicate  that  there  is  something  wrong.  As  the  head  is  held  un- 
steady and  allowed  to  roll  from  side  to  side  the  hairs  are  broken  off 
at  the  occiput,  and  results  in  baldness  in  this  region.  With  any  of 
these  symptoms  present  a  carefully  taken  history  will  reveal  that 
the  infant  has  been  for  some  weeks  or  months  previously  restless  at 
night,  has  suffered  frequently  from  rhinitis  (owing  to  the  frequently 
moist  head),  and  has  been  constipated.  An  unusual  fretfulness  is 
evidenced  in  most  infants,  but  there  is  no  evidence  of  tenderness  or 
pain,  the  fretting  continuing  under  varying  circumstances  and  ir- 
respective of  handling  or  pressure. 

Dentition  is  usually  delayed,  and  the  first  tooth  may  not  appear 
during  the  first  year.  If  there  is  delay  in  the  eruption  of  the  teeth 
it  should  excite  our  suspicion  of  rachitis  as  the  possible  cause,  and 
this  is  especially  true  if  there  is  a  deviation  from  the  normal  in  the 
order  of  the  appearance  of  the  teeth  after  they  have  once  started  to 
erupt  (see  page  16),  or  if  there  is  evidence  of  early  decay  or  irregu- 
lar alignment. 

LATER  SYMPTOMS. — As  the  disease  continues  all  of  the  foregoing 


KACHITIS 


symptoms  are  intensified  and  others  are  added.  These  later  symp- 
toms are  the  most  characteristic  ones,  and  show  the  severity  of  the 
disease;  they  are  the  ones  of  most  interest  to  the  surgeon.  Usually 
the  first  detectable  change  in  the  bony  structure  is  a  beading  of  the 
ribs,  or,  as  it  is  commonly  called,  the  "rachitic  rosary."  The  bead- 
ing is  most  marked  in  the  fifth,  sixth,  and  seventh  ribs,  and  consists 
of  the  formation  of  nodules  at  the  junction  of  the  costal  cartilages 
and  the  ribs.  Sometimes  this  beading  is  very  slight  and  remains  so 

even  though  the  disease  be  severe 
and  the  other  symptoms  marked. 
Most  of  the  slightly  developed  ro- 
saries are  explained  at  autopsy, 
when  it  is  found  that  the  nodules 
are  chiefly  upon  the  internal  sur- 
face. In  average  cases  autopsy 
does  not  show  that  there  is  much 
difference  in  development  betwoen 
the  anterior  and  the  posterior  sur- 
faces. Beading  is  first  detected  by 
palpation,  and  as  it  develops  it 
may  be  readily  seen. 

Thickening  of  the  epipliyseal 
junctions  of  some  of  the  long  bones, 
particularly  at  the  wrists,  ankles, 
and  knees,  soon  follows  the  changes 
in  the  ribs.  It  is  due  to  a  similar 
condition:  excessive  and  irregular 
proliferation  of  cartilage  cells  and 
ossification.  At  first  there  is  a 
knob-like  enlargement,  which  is 

noted  by  palpation,  and  later  on  is  visible.  This  enlargement  lies 
exactly  in  the  line  where  epiphysis  and  diaphysis  join.  The  stature 
of  the  infant  is  but  little  affected  by  this  bony  change,  and  this  is  re- 
markable, considering  that  this  is  the  point  at  which  the  growth  in 
tho  length  of  the  bone  chiefly  occurs.  Children  are  stunted  in  their 
growth  through  the  influence  of  rachitis,  but  in  nearly  every  instance 


FIG.  47. — TYPICAL  CASE  OF  RICKETS. 
Note  the  enlarged  wrist,  ankle  and  knee 
joints,  the  pendulous  abdomen,  um- 
bilical  hernia,    deformed   chest   and 
evident  flabbiness  of  the  musculature. 


SYMPTOMS  1-33 

this  stunting  can  be  directly  traced  to  bending  or  distortion  of  the 
bone  itself. 

The  nodules  are  never  painful  or  tender. 

The  head  of  the  rachitic  child  is  quite  characteristic.  It  appears 
to  be  out  of  proportion  to  the  size  of  the  body,  and  an  actual  enlarge- 
ment may  occur  as  the  result  of  thickening  of  the  frontal  and  parietal 
protuberance.  The  head  assumes  a  somewhat  square  shape,  being 
much  flattened  at  the  occiput  and  the  vertex.  Not  uncommonly  the 
bones  are  so  deeply  grooved  that  it  is  an  easy  matter  to  trace  the 
whole  course  of  a  vessel  over  the  skull  with  the  finger.  This  change 
in  the  shape  and  size  of  the  head  does  not  seem  to  influence  in  any 
degree  the  mentality  of  the  child.  Rachitic  children  are  unusually 
old-fashioned  and  apt  to  be  precocious,  but  this 
is  due  to  the  close  association  with  adults  and 
the  limitation  of  their  activities  among  chil- 
dren of  normal  physical  development. 

There  is  usually  a  marked  delay  in  the 
closure  of  the  sutures  and  the  fontanelles. 

From  what  has  been  said  it  will  be  ob- 
served that  there  is  a  widespread  deficiency  in     FlG  48._COMPARATivE 
the  nutrition  of  the  bones.     The  results  of  this         CHEST  CONTOURS. 

,    f,    .  .  1-11  •       Solid    line    represents    the 

deficiency  are  various  mechanical  changes  m         normal  chest  and  the 


the   shape  of   the   yielding   bony   structures, 
and  therefore  a  change  in  the  body  contour. 

Some  of  the  changes  are  due  to  muscular  action,  some  to  superin- 
cumbent weight  affecting  the  bone,  and  others  to  atmospheric  pres- 
sure and  gastric  and  intestinal  fermentation.  Changes  in  the  shape 
of  the  chest  are  very  common,  the  usual  one  being  that  the  chest  is 
shortened  and  the  sternum  forced  downward.  The  portion  of  the 
chest  near  the  junction  of  the  ribs  and  the  cartilage  is  depressed, 
and  this  tends  to  force  the  lower  portion  of  the  sternum  forward  to 
a  more  or  less  marked  degree.  The  costal  angle  is  commonly  quite 
acute. 

The  vertebrce  are  not  as  hard  as  usual,  and  the  laxity  of  the  mus- 
culature makes  adequate  support  to  the  trunk  impossible.  This 
results  in  bending  of  the  spine  and,  following  the  law  of  gravity,  the 


124 


RACHITIS 


body  is  bent  so  that  the  spinal  column  is  arched  with  the  convexity 
backward.  A  rachitic  curvature  is  general  and  not  localized  as  in 
Pott's  disease.  Rotary  curvature  is  very  uncommon.  If  the  infant 
be  under  the  age  of  six  months  craniotabes  may  be  present.  These 
are  soft  spots  in  the  cranium,  which  are  generally  situated  over  the 
occipital  or  posterior  portions  of  the  parietal  bones,  are  from  one- 
quarter  to  three-quarters  of  an  inch  in  diameter,  and  upon  pressure 
give  to  the  examining  hand  a  sensation  like  the  crackling  of  parch- 
ment under  the  fingers. 
After  six  months  crani- 
otabes are  very  unusual. 
The  secondary 
changes  in  the  lonij 
bones  are  mainly  no- 
ticeable in  the  legs. 
There  may  occur  an 
outward  bowing  of  the 
tibia  and  femora,  re- 
sulting in  bowleg,  or 
the  opposite  condition 
may  occur  and  knock- 
knee  be  the  result.  Bow- 
leg  is  mainly  due  to  the 
mechanical  conditions 


Fio.    49. — TYPICAL   BOWING    OF   THE    LEGS  IN  A 

RACHITIC  CHILD. 
Note  also  the  enlarged  ankle  joints. 


affecting  a  weakened 
bony  and  muscular 
structure,  while  knock- 
knee  is  dependent  upon  hypertrophic  growth  causing  the  tibia  to  form 
an  obtuse  angle  with  the  femur. 

Very  distressing  and  deforming  changes  may  occur  in  any  of  the 
long  bones,  and  while  the  arms  are  not  so  markedly  affected  as  the 
legs,  yet  they  do  not  escape. 

In  the  pelvis  the  commonest  deformity  is  a  shortening  of  the 
anteroposterior  diameter. 

The  abdomen  is  a  prominent  feature  of  rachitis.  It  is  enlarged 
and  tympanitic.  There  are  several  causes  for  this  condition ;  the  dim- 


SYMPTOMS  125 

inislied  thoracic  cavity  causes  a  downward  pressure  of  the  diaphragm, 
while  the  eversion  of  the  lower  ribs  forces  the  liver  and  spleen 
downward.  The  laxity  of  the  abdominal  wall  makes  resistance  to 
this  pressure  but  slight.  There  is  also  almost  constant  fermentation 
going  on  in  the  intestines,  and  the  abdomen  is  thus  distended  until 
finally  all  portions  are  involved.  The  result  of  this  distention,  com- 
bined with  the  deformity  of  the  chest,  forms  a  groove  which  divides 
the  upper  and  narrow  part  of  the  chest  from  the  lower  and  dis- 
tended portion  (that  below  the  diaphragm),  forming  what  is  known 
as  the  rachitic  girdle.  This  girdle  is  usually  not  present  in  the  early 
stages  of  the  disease,  however. 

The  rachitic  child  is  notably  one  who  is  the  subject  of  an  easily 
deranged  digestive  system.  The  gastrointestinal  tract  fails  to  per- 
form its  functions  properly,  so  that  there  is  a  strong  inclination  to 
chronic  meteorism.  Diarrhea  is  not  of  necessity  associated  with 
chronic  intestinal  catarrh,  which  is  the  common  accompaniment  of 
this  disease,  although  such  is  commonly  the  case.  The  lack  of  tone  of 
the  abdominal  musculature  seems  to  be  a  predominant  factor,  and 
therefore  there  is  usually  a  history  of  constipation,  except  during 
the  heated  term,  when  the  rachitic  child  is  particularly  prone  to 
serious  diarrhea. 

The  respiratory  organs  also  exhibit  a  marked  tendency  toward 
oft-repeated  or  chronic  catarrhs,  so  that  the  child  is  constantly  in 
danger  from  the  occurrence  of  serious  disease. 

The  nervous  symptoms  are  many  and  varied.  Restlessness  at 
night  is  one  of  the  earliest.  Attacks  of  laryngismus  stridulus, 
tetany,  or  convulsions  are  not  uncommon,  and  of  the  first  two  of 
these  we  may  say  that  they  occur  most  often  in  rachitic  children. 
The  susceptibility  of  the  rachitic  child  to  convulsive  seizures  is  so 
marked  that  the  slightest  cause  will  sometimes  bring  about  an  at- 
tack. 

In  each  case,  of  course,  all  of  the  associated  symptoms  will  dif- 
fer ;  in  one  infant  it  may  be  the  mucous  surfaces  which  suffer  most, 
in  others  the  respiratory  tract,  the  nervous  system,  or  the  digestive 
tract,  and  the  manifestations  of  the  disease  will  depend  largely  upon 
this  factor  and  the  age  of  the  child.  Active  symptoms  usually  per- 


126 


KACH1TIS 


sist  for  from  two  to  fifteen  months,  but  may  continue  for  longer 
periods. 

Diagnosis. — It  is  only  during  the  earlier  periods  of  the  disease 
that  the  diagnosis  is  difficult,  and  even  then,  after  taking  a  full  his- 
tory of  the  previous  conditions  surrounding  the  child,  particularly 
in  regard  to  the  nutrition,  there  is  little  chance  for  an  error  in  diag- 
nosis. 

An  apparent  difficulty  has  arisen  through  the  fact  that  several 
observers  have  given  widely  divergent  figures  in  reporting  the  fre- 
quency of  the  disease,  but  we  must  recall  that  it  is  only  recently  that 


FIG.  50. — LEG  OF  RACHITIC  CHILD. 

we  have  had  any  clear  idea  of  just  what  the  disease  is,  and  in  some 
places  even  this  knowledge  does  not  appear  to  be  wisely  circulated. 

All  of  the  earlier  symptoms  (anemia,  restlessness  at  night,  head 
sweating,  occipital  baldness,  craniotabes,  delayed  closure  of  the  fon- 
tanelles,  delayed  dentition,  muscular  flabbiness),  taken  singly,  may 
mean  something  entirely  different  from  rachitis,  but,  with  several 
such  symptoms  present  and  a  history  of  faulty  feeding,  they  can 
mean  nothing  else  than  this  disease.  It  is  the  undue  prominence  of 
some  one  symptom  that  is  misleading.  There  may,  for  instance,  be  a 
most  profound  anemia  with  all  of  the  other  symptoms  slight  and 
such  bony  changes  as  are  hardly  noticeable.  Associated  with  a  large 
spleen  such  symptoms  might  readily  lead  to  an  erroneous  diagnosis. 

It  is  this  special  incidence  of  the  disease  against  certain  tissues 


DIAGNOSIS 


127 


that  delays  or  complicates  the  diagnosis.  One  child  is  brought  to 
the  surgeon  because  of  the  large  abdomen,  another  for  the  change  in 
the  shape  and  size  of  the  head,  and  these  particular  symptoms  are 
emphasized  above  all  else.  The  examination  may  show  but  little 
bony  change,  but  the  symptoms  are  none  the  less  directly  due  to 
rachitis. 

The  head  enlargement  may  for  a  time  simulate  that  of  a  slight 
hydrocephalus,  but  in  the  latter  the  forehead  is  more  overhanging 
and  prominent  and  the  whole  breadth  of  the  cranium  is  increased. 
Any  interference  with  the  mentality  should  suggest  the  possibility 
of  hydrocephalus. 


FIG.  51. — CRANIAL     CONTOURS     (COMPARATIVE):     ANTEROPOS- 

TERIOR-ClRCUMFERENCE-TRANSVERSE. 

The  upper  figure  represents  the  hydrocephalic  head  and  the 
lower  figure  represents  the  rachitic  head. 

If  bony  changes  are  slight  and  the  musculature  is  markedly  af- 
fected (which  is  not  unusual)  there  may  be  a  marked  similarity  to 
paralysis.  This  is  determined  by  a  study  of  the  electrical  reactions 
and  the  presence  or  absence  of  the  various  superficial  reflexes. 

The  possibility  of  mistaking  syphilis  is  rather  remote,  for  in  the 
beginning  the  lesions  of  syphilis  are  more  like  soft  infiltrations  over 
the  bones,  and  the  part  affected  is  not  the  end  of  the  bone,'  but  the 
junction  of  the  shaft  and  the  epiphysis,  or,  later  in  the  disease,  the 
shaft  itself.  The  history  of  the  two  diseases  is  entirely  different, 
and  the  bony  changes  are  much  earlier  in  rachitis  than  in  syphilis. 


128  RACHITIS 

A  rachitic  type  of  skull  occurring  without  any  of  the  other 
evidences  of  rachitis  should  at  once  suggest  the  probability  of  syphilis 
as  the  cause. 

Treatment. — The  prevention  of  rachitis  rarely  comes  within  the 
province  of  the  surgeon,  and  yet  its  main  principles  must  be  under- 
stood if  he  is  to  successfully  attack  the  disease  as  it  is  exhibited  in  the 
form  of  deformity  in  the  neglected  cases. 

These  will  be  very  briefly  considered.  The  surest  way  to  pre- 
vent rachitis  is  to  give  the  infant  breast  milk.  If  this  is  impractical 
because  of  conditions  affecting  the  mother  or  her  milk,  a  wet-nurse 
may  be  secured,  but  if  this  latter  also  be  impossible  the  infant  should 
be  fed  upon  fresh  cow's  milk,  modified  but  not  pasteurized  or  ster- 
ilized. The  latter  methods  of  treatment  of  the  milk  are  entirely  un- 
necessary if  the  milk  is  clean  to  start  with,  and  such  treatment  of 
the  food  can  occasionally  be  "traced  as  the  direct  cause  of  those  cases 
that  formerly  were  classed  under  the  term  ''scurvy  rickets."  These 
borderline  cases  do  not  do  well  on  anything  but  the  fresh  cow's  milk. 
But  fresh  milk  must  be  properly  modified,  so  that  the  fat  content  is 
sufficient  for  the  infant's  needs.  To  avoid  unnecessary  repetition 
the  reader  is  referred  to  page  120  for  elucidation  upon  this  point. 
The  hygiene  of  the  infant  must  be  the  best  obtainable.  When  the 
first  symptoms  appear,  no  matter  how  slight,  every  precaution  must 
be  taken  to  secure  the  proper  hygienic  care  and  food  for  the  needs 
of  the  particular  infant  under  observation. 

Fresh  air  and  sunshine  in  abundance  are  absolutely  necessary ; 
the  latter  all  day  and  the  former  day  and  night.  These  are  of  great 
importance,  because  they  have  such  a  marked  influence  upon  the 
general  nutrition  of  the  child. 

If  breast  fed,  the  mother's  milk  should  be  examined  and  the 
deficiency  corrected  if  possible.  If  lactation  has  been  unduly  pro- 
longed, or  there  is  a  barrier  to  the  correction  of  the  deficiency,  ac- 
cessory feeding  must  be  considered.  With  the  breast  milk  as  the 
basis  for  working  it  out  a  formula  of  modified  fresh  cow's  milk 
should  be  given  suited  to  the  particular  child's  needs,  and  as  rapidly 
as  is  consistent  with  safety  the  breast  may  be  withdrawn  in  favor  of 
the  artificial  feeding. 


TREATMENT 


129 


If  the  infant  is  artificially  fed  an  inquiry  must  determine  the 
deficiency  or  fault  in  the  feeding,  and  this  must  be  corrected.  This 
will  require  that  all  of  the  well-known  principles  of  scientific  infant 
feeding  be  followed  with  clearness,  precision,  and  system  in  each 
individual  instance.  In  this  the  surgeon  will  often  require  the  aid 
of  the  pediatrist.  No  care  or  attention  to  detail  in  this  matter  of 
hygiene  and  food  can  be  too  exacting,  for  even  an  occasional  relaxa- 
tion of  persistent  effort  may  result  in  some  complication  which  will 
prove  disastrous  to  the  infant. 

While  there  are  instances  where  the  detec- 
tion of  the  fault  in  the  diet  is  very  difficult, 
they  are  few;  in  nearly  every  case  the  dietetic 
fault  is  one  that  is  so  evident  that  it  cannot  be 
overlooked. 

The  general  principle  is  to  give  the  fats  up 
to  their  maximum  limit,  with  great  caution  that 
they  are  not  disturbing  the  digestion  and  are 
being  properly  assimilated.  The  proteids  may 
also  be  given  up  to  the  standard  for  the  aver- 
age healthy  infant  of  the  same  age,  but  the 
carbohydrates  are  to  be  kept  somewhat  below 
what  would  be  normal  and  are  never  allowed 
to  interfere  with  the  ingestion  and  assimilation 
of  the  fat,  which  is  the  all-important  element. 

Much  can  be  gained  by  the  administration 

of  cod-liver  oil  or,  in  fact,  any  oil  that  is  well  tolerated  by  the  diges- 
tive system.  In  the  giving  of  the  oil  the  minimum  dose  should  al- 
ways be  given,  and  as  it  is  observed  that  it  is  well  tolerated  (causing 
no  nausea  or  digestive  disturbance),  it  may  be  cautiously  increased. 
Five  or  ten  minims  well  tolerated  is  far  superior  to  a  dram  or  more 
poorly  digested. 

Phosphorus  has  many  advocates,  and,  while  there  seems  to  be 
much  to  be  desired  in  the  explanation  of  its  effect  as  well  as  in  its 
clinical  results,  it  may  be  used  judiciously  in  conjunction  with  other 
treatment  (1-100  to  1-200  grain  three  or  four  times  daily).  As  the 
drug  is  usually  prescribed  in  oil  we  are  often  left  in  doubt  as  to  just 


FIG.    52. — M  A  R  K  E  D 
RACHITIC   DEFORMITY. 


130  SCORBUTUS 

what  credit  should  be  given  to  the  vehicle  in  the  apparently  good 
results  in  some  cases. 

On  purely  theoretical  grounds  calcium  may  be  given  (calcium 
phosphate  precipitated  or  calcium  hypophosphite)  mixed  with  the 
food.  There  is  absolutely  no  value  in  giving  lime  water  in  the  food 
to  obtain  the  effect  attributed  to  calcium. 

The  anemia  is  combated  with  fresh  beef -juice  and  the  adminis- 
tration of  iron.  Realizing  the  ease  with  which  deformity  occurs 
through  undue  muscular  effort  or  mechanical  factors  affecting  the 
bony  structures,  it  is  absolutely  necessary  to  control  the  activities 
of  the  child  while  there  exists  the  danger  of  deformity.  For  this 
purpose  it  may  even  be  necessary  at  times  to  use  splints  combined 
with  other  enforced  rest,  but  restricted  activity  usually  suffices. 

But  if  deformity  has  already  occurred,  what  should  be  done  ?  If 
effectual  means  are  taken  to  prevent  mechanical  factors  from  further 
action  it  is  sometimes  remarkable  what  marked  improvement  takes 
place  in  the  part.  Rest  combined  with  massage  and  gentle  pressure 
often  accomplishes  much  in  the  limitation  of  deformity. 

The  regional  treatment  of  deformity  due  to  rachitis  is  fully  con- 
sidered under  the  several  regional  headings. 

CHAPTER  XXIII 

SCOEBUTUS 

While  the  occurrence  of  this  disease  was  noted  occasionally  as 
far  back  as  the  seventeenth  century,  yet  it  is  only  within  quite  recent 
years  that  it  has  been  thoroughly  understood  and  recognized  gener- 
ally. It  is  the  same  as  the  old-time  scurvy  of  sailors,  and  is  brought 
about  by  the  conditions  of  modern  life.  The  disease  is  a  constitu- 
tional malnutrition,  and  is  evidenced  chiefly  by  anemia  and  a  gen- 
eral hemorrhagic  tendency,  all  of  which  are  definitely  connected  with 
a  dietetic  fault.  Its  close  association  with  rachitis  in  infancy  has 
led  to  much  misunderstanding  of  both  diseases,  but  especially  of 
scorbutus. 

Age  Incidence. — The  knowledge  of  the  age  incidence  of  the  dis- 
ease may  be  of  considerable  aid  in  the  recognition  of  scorbutus.  Its 


ETIOLOGY  131 

onset  is  practically  limited  to  the  last  half  of  the  first  year  of  life, 
and  in  the  great  majority  of  instances  its  first  symptoms  arc  noted 
between  the  sixth  and  the  ninth  months.  So  constant  and  pro- 
nounced is  this  age  incidence  that  if  an  infant  between  the  ages  of 
six  months  and  one  year  exhibits  any  tenderness  of  the  limbs  or  re- 
fuses to  use  them  as  actively  as  usual,  it  should  suggest  the  possi- 
bility of  this  disease.  However,  this  fact  must  not  vitiate  the  further 
fact  that  more  uncommonly  scorbutus  may  attack  the  infant  of  four 
or  five  months,  or  may  be  delayed  in  its  appearance  until  well  into 
the  second  year  of  life. 

Etiology. — Unlike  rachitis,  which  is  most  frequent  among  the 
poorer  classes  and  certain  races,  scorbutus  shows  special  preference 
for  the  middle  and  richer  classes.  There  is  some  explanation  for 
this  in  the  fact  that  it  is  unusual  to  find  that  the  infant  among  the 
poorer  classes  is  exclusively  fed  upon  one  article  of  diet,  and  this 
immediately  brings  us  to  a  consideration  of  the  most  important 
etiological  factor  of  all :  the  diet.  As  a  matter  of  fact,  the  diet  may 
be  stated  as  being  the  sole  cause  of  the  disease. 

From  time  to  time  every  element  of  the  food  has  been  assigned 
as  the  probable  cause,  and  mother's  milk,  which  is  the  ideal  infant 
food,  has  several  cases  of  scorbutus  charged  against  it.  There  is 
probably  no  single  food  that  has  not  been  blamed  for  the  occurrence 
of  the  disease,  and  so  we  find  that  raw  cow's  milk  has  infrequently 
been  assigned  as  the  cause.  Peptonized,  sterilized,  and  pasteurized 
milks  all  have  shown  many  cases  of  scorbutus  to  follow  their  use. 
But  the  large  majority  of  histories  of  the  feeding  will  show  that  the 
infant  has  been  fed  exclusively  upon  one  of  the  patent  foods  or  con- 
densed milk,  and  this  has  suggested  the  theory  that  an  infant  food 
that  is  treated  so  as  to  preserve  it  in  the  operation,  loses  something 
which  is  essential  to  the  perfect  performance  of  nutrition.  In  other 
words,  the  lack  of  a  fresh  food  seems  to  be  the  common  factor  in 
the  cause  of  scorbutus.  The  theory  is  that  the  antiscorbutic  agent 
in  a  food  is  something  which  is  vital  and  is  destroyed  by  the  proc- 
esses (prolonged  or  excessive  heat)  which  are  sometimes  necessary 
to  its  preservation. 

At  the  present  time,  however,  irrespective  of  theory,  we  must 


132  SCORBUTUS 

accept  what  thorough  investigation  has  seemed  to  prove:  that  scor- 
butus  follows  the  prolonged  use  of  any  food  that  is  unsuited  to  the 
infant's  needs ;  that  there  are  therefore  certain  kinds  of  food  which 
must  result  eventually  in  the  disease,  and  that  the  further  removed 
the  food  is  from  the  natural  nutriment  of  the  infant  the  more  cer- 
tain is  the  disease  to  occur. 

Pathology. — Fatal  cases  are  rare  because  of  the  striking  results 
of  treatment,  but  in  the  few  instances  in  which  autopsy  has  been 
performed  the  changes  that  have  been  found  are  almost  all  due  to 
hemorrhage.  Under  the  periosteum  of  the  long  bones  are  found 
hematomas  which  have  stripped  the  covering  from  the  bone.  There 
may  be  separation  of  the  epiphysis  in  aggravated  cases.  The  sub- 
periosteal  hemorrhages  are  most  commonly  found  about  the  shaft 
and  the  lower  end  of  the  femur,  but  may  occasionally  be  found  over 
the  tibia  and  other  long  bones.  The  bone  structure  about  the  epiphy- 
sis is  always  congested  and  hemorrhagic.  Hemorrhagic  spots  are 
common  in  the  skin,  the  pleura,  pericardium,  the  liver,  spleen,  and 
other  viscera,  and  subcutaneous  hematomas  are  frequent.  The  gums 
are  swollen,  hemorrhagic,  and  edematous,  and  the  teeth  are  loosely 
attached. 

Symptomatology. — Swellings  of  the  gums,  with  or  without  a  ten- 
dency to  bleed,  pain  in  the  joints,  and  swellings  about  the  limbs  are 
the  most  prominent  symptoms  of  a  well-advanced  case  of  scorbutus. 
But  the  classic  symptoms  must  not. mislead  the  surgeon,  for  long 
before  these  appear  it  is  possible  to  recognize  the  disease.  Many  of 
the  cases  begin  most  insidiously,  so  that  weeks  may  go  by  before 
there  is  any  marked  manifestation  of  the  disease.  If  an  infant  has 
been  for  a  prolonged  period  fed  upon  a  proprietary  or  other  food, 
and  begins  to  exhibit  stationary  weight  or  a  failure  to  keep  up  the 
usual  steady  and  consistent  gain,  is  fretful  and  uneasy,  and  the  food 
does  not  seem  to  agree  as  well  as  formerly,  that  infant  should  be  sus- 
pected of  having  scorbutus.  Such  symptoms  strongly  indicate  that 
conclusion,  and  two  or  three  days'  treatment  with  an  antiscorbutic 
diet  (see  page  137)  would  absolutely  prove  it.  As  the  same  diet  that 
causes  scorbutus  may  be  so  deficient  in  fat  as  to  favor  the  develop- 
ment of  rachitis,  we  not  uncommonly  find  the  two  diseases  in  com- 


SYMPTOMATOLOGY  133 

bination.  However,  this  must  not  be  assumed  as  an  evidence  that 
the  two  diseases  have  any  relation  between  them;  they  are  entirely 
distinct,  but  the  same  dietetic  faults  may  bring  about  the  occurrence 
of  such  disease.  After  some  weeks  of  indefinite  symptoms,  but  such 
as  should  arouse  suspicion  because  of  the  history  of  the  faulty  feed- 
ing, the  most  striking  feature  of  scorbutus  is  apt  to  show  itself.  This 
is  the  tenderness  of  the  limbs,  which  is  more  in  evidence  in  the 
lower  than  in  the  upper  ones.  Coincident  with  the  tenderness  or 
closely  following  it,  there  is  often  palpable  or  visible  swelling  of  the 
affected  limb,  but  it  must  be  remembered  that  this  swelling  is  oc- 
casionally so  slight  that  it  may  be  overlooked.  It  is  the  result  of 
subperiosteal  hemorrhage,  and  therefore  it  is  readily  observed  that 
only  the  most  gentle  palpation  will  reveal  it.  The  swelling  extends 
for  some  distance  along  the  shaft  of  the  bone,  and  is  never  limited 
to  the  epiphyseal  region  alone.  As  has  been  stated  in  the  pathology, 
the  swellings  are  mostly  found  about  the  lower  end  of  the  femur, 
but  may  be  over  any  of  the  long  bones,  even  the  ribs.  In  neglected 
cases  the  whole  or  any  part  of  the  bone  may  be  surrounded  by  these 
subperiosteal  hemorrhages.  Rarely  such  hemorrhages  may  occur  over 
the  bones  of  the  skull  and  produce  large  bluish  swellings  which  look 
like  sarcoma. 

Quickly  following  the  evidences  of  tenderness,  or,  in  fact,  even 
preceding  any  such  evidence,  there  may  occur  a  loss  of  motion  of 
the  limb.  And  just  here  is  where  error  is  made;  such  cases  are 
commonly  not  diagnosed  as  scorbutus,  but  rheumatism,  infantile 
spinal  paralysis,  and  a  host  of  other  conditions  are  blamed  for  the 
inability  to  move  the  limb  freely. 

These  mistakes  should  hardly  occur,  because  the  tenderness  is 
always  acute,  and  the  very  severe  pain  on  passive  motion,  with  the 
swellings  and  local  thickenings,  coupled  with  the  history  of  faulty 
feeding  and  the  associated  symptoms,  should  make  the  diagnosis  cer- 
tain. The  loss  of  motion  in  the  limb  is  due  at  first  probably  to  fear 
of  pain,  but  there  is  soon  a  mechanical  disability  in  an  untreated  case. 
The  periosteum  is  stripped  off  of  the  bone  by  the  hemorrhage,  and 
the  muscles  in  the  immediate  neighborhood  may  be  infiltrated  with 
blood  and  serum.  In  less  frequent  instances  epiphyseal  separation 


134  SCORBTJTUS 

occurs  as  the  result  of  extensive  hemorrhage,  and  the  disability  is 
complete.  The  most  careful  handling  of  such  a  limb  is  the  only 
safeguard  against  further  separation  of  the  parts  and  the  occurrence 
of  fracture. 

When  edema  occurs  over  the  affected  parts  of  the  limb,  as  is  oc- 
casionally the  case,  the  subperiosteal  swellings  cannot  be  mapped  out. 

The  gums  also  show  characteristic  changes ;  they  become  swollen 
and  somewhat  brighter  in  color  than  is  usual,  with  a  dark  reddish  or 
purple  line  close  to  the  teeth.  When  the  disease  becomes  well  ad- 
vanced hemorrhages  take  place  and  the  gums  are  very  friable,  allow- 
ing the  teeth  to  become  much  loosened.  The  condition  of  the  gums  is 
always  worse  about  the  site  of  a  tooth.  However,  this  swelling  and 
redness  of  the  gums  are  not  always  present,  even  in  cases  of  moderate 
severity,  and  it  may  require  somewhat  close  examination  to  detect 
anything  abnormal.  The  occasional  development  of  this  character- 
istic appearance  of  the  gum  behind  the  tooth,  and  but  slightly  in 
front  of  it,  should  lead  to  an  examination  of  this  area  in  all  sus- 
pected cases  of  scorbutus.  If  no  teeth  have  erupted  the  appearance 
of  the  gums  is  quite  different,  for  hemorrhage  is  not  so  likely  to  take 
place,  and  the  only  evidence  may  be  a  few  petechial  spots  over  the 
gum,  and  particularly  over  the  point  where  the  teeth  will  first  appear. 

On  the  other  hand,  the  gums  may  be  markedly  affected,  and  the 
other  symptoms  of  the  disease  be  but  slight  in  comparison,  but  such 
instances  are  not  common.  An  ecchymosis  developed  without  the 
clear  history  of  a  traumatism  in  an  infant  should  always  excite  the 
suspicion  of  scorbutus  as  the  cause.  Or  if  an  injury  is  shown,  and 
the  local  signs  due  to  hemorrhage  subcutaneously  are  out  of  all  pro- 
portion to  the  traumatism,  it  should  suggest  the  same  thing.  An  il- 
lustrative instance  may  be  of  value.  We  were  called  to  see  an  infant 
girl  of  eight  months  on  account  of  a  fall  which  she  had  out  of  bed, 
and  found  that,  while  the  infant  had  fallen  upon  her  back  and  did 
not  seem  to  be  harmed,  yet  there  quickly  developed  an  extensive 
discoloration  of  the  eye,  and  there  was  later  some  bleeding  from  the 
mouth.  Examination  showed  that  the  gums  were  badly  swollen  and 
bleeding,  and  that  there  was  tenderness  in  the  limbs.  The  history 
showed  that  the  infant  had  been  unusually  fretful  and  rebelled  against 


PROGNOSIS  135 

any  handling  for  a  few  days,  and  the  diet  had  never  been  anything 
but  one  of  the  proprietary  foods.  The  treatment  soon  confirmed  the 
diagnosis  of  scorbntns. 

Hemorrhages  from  the  mucous  surfaces  may  occur,  but  these  are 
by  no  means  as  constant  or  noticeable  as  the  more  characteristic 
symptoms. 

Hematuria  is  probably  present  in  a  large  number  of  the  cases,  but 
the  difficulty  of  the  microscopic  examination  and  the  prompt  response 
to  treatment  have  made  this  detail  one  that  has  been  neglected. 

There  is  no  general  rise  in  the  temperature  in  scorbutus,  in  fact, 
pyrexia  is  decidedly  the  exception  rather  than  the  rule.  The  occa- 
sional rises  of  temperature  to  101°,  102°,  or  103°  F.  are  often  diffi- 
cult of  explanation,  for  they  are  present  under  so  many  varying  con- 
ditions and  are  so  short  in  duration. 

We  must,  however,  be  on  our  guard  in  this  matter,  so  that  we 
may  rightly  give  fever  its  proper  value  in  the  matter  of  diagnosis. 
It  would  be  an  easy  matter  if  associated  with  edema  and  fever  to 
attribute  the  symptoms  of  scorbutus  to  an  infection,  like  suppurative 
periostitis.  But  subsequent  examinations  would  eliminate  this,  and 
if  the  possibility  of  scorbutus  was  carefully  considered  there  could 
hardly  exist  any  doubt  as  to  the  true  condition. 

Diagnosis. — Rheumatism  may  often  be  considered  when  scorbutus 
is  the  real  cause  of  the  symptoms.  But  the  swelling  of  scorbutus  is 
seldom  in  the  joint  itself,  but  extends  up  the  shaft  of  the  bone. 
Rheumatism  is  exceedingly  rare  in  infants,  and  one  need  never  be 
long  in  doubt.  There  is  a  real  difficulty,  however,  if  a  hasty  ex- 
amination is  made  of  mistaking  the  scorbutus  for  a  paralysis.  This 
will  be  cleared  up  quickly  by  the  histories,  which  are  entirely  dif- 
ferent, and  the  demonstration  of  the  fact  that  a  true  paralysis  does 
not  exist. 

Osteosarcoma  has  in  some  cases  simulated  scorbutus  when  the 
local  signs  were  alone  considered,  but  the  accompanying  symptoms  of 
each  should  make  this  error  impossible. 

Prognosis. — In  this  disease  the  effect  of  treatment  is  so  prompt 
and  so  remarkable  that  there  are  few  diseases  which  equal  it  in  this 
respect.  Under  the  proper  measures  the  pain,  the  tenderness,  the 


136  SCORBUTUS 

possible  immobility  of  the  limb,  and  the  other  associated  symptoms 
clear  up  to  a  considerable  extent  within  the  first  one  or  two  days. 
After  this  first  striking  improvement  there  is  a  less  marked  and  yet 
a  steady  and  rapid  improvement  in  all  of  the  symptoms,  so  that 
within  one  week  the  infant  should  be  practically  well.  If  there  has 
been  thickening  about  the  bone  it  may  take  months  to  entirely  disap- 
pear. Large  hematomas  may  persist  for  a  week  or  two.  Unfavorable 
factors  are  the  occurrence  of  a  persistent  diarrhea  and  the  evidences 
of  a  renal  involvement  (as  shown  by  an  examination  of  the  urine), 
and  particularly  if  there  is  evidence  of  pus  in  the  urine. 

It  must  be  recalled  that  scorbutus  is  not  a  disease  which  will  run 
a  more  or  less  definite  course,  but  is  one  which  will  be  progressive 
and  chronic  in  its  course,  until  the  appropriate  measures  are  insti- 
tuted to  control  it.  So  unrecognized  cases  may  become  so  bad  that 
the  change  in  diet  causes  but  a  transitory  improvement,  and  the  in- 
fant dies  of  sheer  exhaustion.  If  already  weakened  by  previous  dis- 
ease then  the  occurrence  of  scorbutus  in  an  infant  is  a  very  serious 
matter.  Many  cases  are  complicated  with  pneumonia,  and  are  nearly 
always  fatal. 

Prophylaxis  and  Treatment. — These  two  are  so  closely  allied  to 
one  another  that  there  is  a  distinct  advantage  in  considering  them 
together.  Prevention  of  such  a  serious  disease  is  of  prime  impor- 
tance, and  prophylaxis  demands  an  intimate  knowledge  of  the  eti- 
ology, which  has  already  been  discussed,  and  careful  attention  to  the 
details  of  infant  feeding,  which  would  prevent  the  dietetic  fault 
which  causes  the  disease.  We  believe  it  to  be  excellent  practice,  and 
therefore  have  insisted  upon  it  in  our  own  work,  and  have  recom- 
mended also  in  another  volume  that  every  infant,  whether  breast-fed 
or  artificially  fed,  be  given  orange  juice  daily  beginning  with  the 
end  of  the  third  month  of  life.  There  is  no  more  certain  or  simple 
way  in  which  we  can  prevent  the  occurrence  of  scorbutus  than  by  this 
method.  However,  the  great  value  of  this  measure  must  not  detract 
from  the  endeavor  which  must  be  made  to  gradually  correct  the 
fault  in  the  diet.  Occasionally  it  may  be  found  that  an  infant  does 
not  tolerate  orange  juice  well,  and  in  such  instances  fresh  grape 
juice  may  be  substituted.  The  juice  from  perfectly  fresh  beef  an- 


PROPHYLAXIS  AND  TREATMENT        137 

swers  a  similar  purpose,  but  owing  to  its  stimulating  effect  its  use 
in  infancy  is  much  more  restricted  than  the  fruit  juices. 

Given  a  case  in  which  the  symptoms  of  scorbutus  are  present, 
the  first  procedure  must  be  to  change  the  food.  Many  different 
foods  have  been  recognized  as  the  causative  factor  in  scorbutus, 
and  therefore  it  is  not  necessary  for  the  handling  of  an  individual 
case  to  know  all  of  these.  The  fact  that  must  be  recognized,  how- 
ever, is  that  the  diet  that  the  individual  infant  is  taking  is  at  fault 
and  must  be  changed.  The  error  in  the  diet  is  usually  so  glaring 
that,  once  the  surgeon's  attention  is  called  to  it,  it  is  detected,  for  the 
correction  of  the  dietetic  faults  which  bring  about  this  disease  re- 
quires but  little  exact  knowledge  of  infant  feeding. 

All  "dead  food"  must  be  discontinued,  including  condensed  milk, 
sterilized  or  pasteurized  milk,  and  proprietary  foods.  The  most 
serviceable  substitute  for  the  "dead  food"  is  raw  cow's  milk  prop- 
erly modified  for  the  age  of  the  infant.  Such  a  food  in  itself  would 
contain  sufficient  of  the  antiscorbutic  element  to  cure  the  infant,  but 
there  are  other  articles  of  diet  which  contain  it  in  greater  abundance. 
Thus  we  make  use  of  these  and  give  the  infant  beef  juice,  orange 
juice,  and  potato.  The  potato,  of  course,  is  not  used  if  the  infant  is 
very  young,  but  its  use  is  reserved  for  older  infants. 

The  failure  of  the  fruit  juices  can  only  be  attributed  to  insuffi- 
cient dose;  the  scorbutic  infant  should  have  the  juice  of  a  moderate 
sized  orange  daily,  and  if  beef  juice  is  used  it  may  be  given  in 
tablespoon  doses  night  and  morning.  We  might  emphasize  that  the 
commercially  prepared  beef  juices  are  absolutely  worthless  in  this 
disease;  the  juice  must  be  from  fresh  (and  better  uncooked)  beef. 

The  potato  is  prepared  by  boiling  or  steaming  and  forcing 
through  a  fine  sieve,  after  which  a  tablespoonful  is  given  dry  or 
rubbed  up  with  cream  or  milk,  and  this  dose  is  administered  twice  or 
three  times  daily.  This  constitutes  the  dietetic  treatment  of  scor- 
butus. 

The  further  treatment  consists  in  restricting  the  activities  of 
the  infant  so  as  to  protect  it  from  pain  and  also  from  possible  in- 
jury. If  the  limbs  are  swollen  they  should  be  wrapped  in  cotton 
and  kept  in  position  by  a  splint  if  necessary.  An  excellent  plan  in 


138  SYPHILIS 

some  instances  is  to  place  the  infant  upon  a  pillow  and  fasten  the 
limbs  with  broad  tapes;  then  the  infant  may  be  carried  from  place  to 
place  without  danger  of  any  injury. 

The  toilet  of  the  mouth  should  be  rigid  so  as  to  limit  and  pos- 
sibly prevent  bacterial  decomposition  about  the  gums. 

After  the  complete  subsidence  of  active  symptoms  the  nutrition 
of  the  infant  should  be  brought  up  to  the  highest  possible  point  by  a 
careful  and  detailed  attention  to  the  influence  of  fresh  air,  sunshine, 
hygienic  surroundings,  a  proper  diet,  and  a  well-selected  tonic  suited 
to  the  individual  need.  There  is  no  other  disease  in  which  the 
clinical  picture  may  appear  so  discouraging  and  still  have  such  a 
remarkable  response  to  appropriate  treatment  by  diet  and  without 
the  use  of  drugs.  Neither  is  there  one  in  which  the  application  of 
the  proper  measures  for  its  relief  so  completely  and  immediately 
confirms  the  diagnosis. 


CHAPTER  XXIV 

SYPHILIS 

This  disease,  as  it  occurs  during  childhood,  may  be  acquired  or 
inherited. 

ACQUIRED    SYPHILIS 

Acquired  syphilis  is  by  far  the  least  common  and,  in  fact,  is  quite 
rare,  but  the  possibility  of  its  occurrence  in  this  manner  must  not  be 
overlooked.  The  means  of  its  acquisition  are  many;  it  may  be  ac- 
quired from  the  mother  during  the  act  of  birth,  it  may  be  that  later 
inoculation  from  the  same  source  is  the  cause.  Through  the  contact, 
accidental  or  otherwise,  with  an  infected  nurse,  relative,  or  friend, 
through  the  medium  of  infected  articles,  as  bottles,  toys,  and  so 
forth,  or  by  any  of  the  constant  means  the  disease  may  be  acquired 
by  children.  In  the  large  majority  of  the  acquired  forms  the  ac- 
quisition has  become  possible  through  innocence  or  through  igno- 


CONGENITAL    SYPHILIS  13!) 

ranee.  However,  there  are  enough  instances  recorded  of  precocious 
children  acquiring  the  disease  through  the  channels  of  sexual  contact 
with  the  opposite  sex,  that  this  factor  must  be  considered.  The  oc- 
casional instance  of  a  primary  lesion  situated  about  the  anus  occur- 
ring as  the  result  of  sexual  contact  of  an  infected  man  gives  us  food 
for  thought. 

The  possibility  of  vaccination  as  the  mode  of  inoculation  must 
be  thought  of,  because  in  a  few  instances  the  humanized  virus  is  still 
used.  Criminal  assault  is  not  an  unusual  means  of  infection,  and 
in  just  such  cases  the  utmost  skill  and  precaution  must  be  exercised 
to  differentiate  between  the  congenital  and  acquired  forms. 

ISTo  matter  how  young  the  child  may  be,  a  somewhat  typical 
course  of  the  phenomena  of  syphilis,  following  the  appearance  of  a 
chancre,  or  primary  adenopathy,  is  the  only  substantial  proof  which 
we  possess  that  the  case  is  one  of  acquired  syphilis.  Snuffles,  pem- 
phigus, and  pseudoparalysis  are  not  a  part  of  the  clinical  picture  in 
the  acquired  form,  while  the  occurrence  of  a  chancre,  no  matter 
what  its  situation,  settles  all  uncertainty  as  to  the  disease  being 
acquired. 

By  whatever  means  acquired  this  form  of  the  disease  runs  a 
course  which  is  practically  similar  to  that  of  adult  life,  with  the 
one  exception  that  it  is  always  a  more  acute  and  severe  disease,  and 
not  uncommonly  results  in  a  fatal  issue  as  far  as  life  is  concerned. 
The  inability  to  accurately  make  the  distinction  between  the  two 
forms  may  result  disastrously  to  the  reputation  of  some  innocent 
person. 

CONGENITAL    SYPHILIS 

That  inoculation  with  the  disease  is  possible  at  the  time  of  con- 
ception is  admitted  generally,  or  the  disease  may  be  transmitted  at 
some  later  period  of  intrauterine  life.  These  facts  have  brought 
about  a  discussion  among  writers  as  to  the  proper  word  to  use  in 
distinguishing  these  cases.  Many  claim  that  those  cases  coming 
under  the  former  heading  should  be  called  "inherited  syphilis,"  while 
the  latter  class  of  cases  must  be  termed  "congenital  syphilis."  It  is 


140  SYPHILIS 

possible  to  make  this  distinction,  but  is  it  of  practical  value  to  do  so  ? 
The  manifestations  of  the  disease,  whether  "inherited"  or  "con- 
genital," show  no  clinical  differences,  therefore  we  may  with  reason 
make  a  choice  of  either  term,  and  personally  we  will  select  the  term 
congenital  syphilis. 

Etiology. — Congenital  syphilis  may  arise  as  the  result  of  infec- 
tion through  the  spermatozoon,  from  the  ovum,  or  from  both.  And 
this  infection  may  be  coincidental  with  conception,  or  may  be  delayed 
for  a  short  period  and  occur  through  the  influence  of  the  maternal 
tissues.  If  the  father  be  syphilitic  the  spermatozoon  may  convey 
the  disease  to  the  offspring.  However,  after  union  between  the 
spermatozoon  and  the  ovum  has  taken  place,  if  the  father  is  subse- 
quently a  victim  to  the  disease  he  can  only  infect  the  embryo  in- 
directly through  the  medium  of  the  mother. 

The  mother's  possibilities  of  transmitting  the  disease  are  great. 
She  may  begin  by  infecting  the  unimpregnated  ovum  itself,  and 
continue  her  activity  along  this  line  until  the  time  of  birth,  so  that 
she  is  a  factor  that  must  be  considered. 

If  the  mother  is  already  pregnant,  and  during  this  pregnancy 
acquires  the  disease,  the  strong  probabilities  are  that  she  will  not 
infect  her  offspring.  Of  course,  it  may  be  readily  observed  that  the 
later  in  the  pregnancy  such  inoculation  occurs  the  better  the  chances 
for  the  offspring's  escape. 

If  the  ovum  of  the  woman  be  perfectly  healthy  and  not  syphilized 
the  spermatozoon  from  a  syphilitic  father  is  capable  of  inoculating 
it,  and  the  result  of  such  conception  will  be  a  syphilitic  infant. 
Clinically  it  cannot  be  determined  that  such  a  woman  acquires  the 
disease,  although  that  she  has  some  modified  form  of  syphilis  as  the 
result  of  having  carried  a  syphilitic  infant  seems  to  be  proven  by  the 
fact  that  she  may  nurse  the  syphilitic  infant  without  acquiring  the 
disease.  This  another  uninfected  woman  could  not  do.  Of  course 
with  such  a  proposition  we  must  assume  that  the  infant  has  a  syph- 
ilitic stomatitis  or  lesion  in  the  mouth,  making  infection  easy.  The 
dangers  of  transmission  are  greatest  during  the  active  and  secondary 
stages  of  the  disease,  while,  if  impregnation  takes  place  during  the 
tertiary  stage,  or  when  the  infected  parent  has  been  under  adequate 


COXGEXITAL    SYPHILIS  141 

treatment  for  a  long  period,  the  chances  of  infection  of  the  infant 
are  slight. 

Types  of  Disease. — Ordinarily  we  think  of  congenital  syphilis 
only  as  it  shows  in  a  more  or  less  virulent  infection  in  the  offspring. 
But,  on  the  other  hand,  there  may  be  the  hereditary  transmission  of 
constitutional  changes  which  are  the  result  of  the  specific  poison  in 
the  parent.  The  manifestations  of  these  changes  in  the  offspring  are 
in  more  or  less  marked  general  disturbances  which  are  not  traceable 
to  other  sources.  If  we  consider  only  the  first  type  of  cases  we  are 
taking  a  very  narrow  view  of  the  disease.  In  this  type  we  study 
changes  which  are  brought  about  through  the  influence  of  the  direct 
hereditary  transmission  of  germs.  In  the  other  type  we  are  not  of 
necessity  dealing  with  that  situation,  but  with  a  constitutional  trans- 
mission which  is  resulting  in  the  various  anomalies  as  stated. 

These  are  dependent  upon  and  connected  with  the  destructive 
effect  of  the  disease  upon  the  general  health  and  condition  of  the 
parents.  In  other  words,  we  frequently  see  infants  exhibiting  tissue 
changes  which  are  attributable  to  syphilitic  infection,  but  without 
any  evidences  of  the  usual  syphilitic  lesions. 

Pathology. — There  are  not  always  characteristic  lesions,  but  there 
are  evidences  in  the  viscera,  the  bones,  and  the  skin  of  hyperplasias 
of  the  connective  tissue  elements,  and  these  are  suggestive. 

The  most  common  visceral  change  is  in  the  liver,  which  is  usually 
enlarged,  and  may  be  the  site  of  round  cell  infiltration  and  a  gen- 
eral proliferation  of  the  interlobular  connective  tissue.  This  change 
follows  quite  closely  the  course  of  the  smaller  arteries.  Generally 
there  is  an  associated  degeneration  of  the  parenchymatous  cells.  The 
gross  appearance  of  such  a  liver  is  a  speckled  viscus,  covered  with 
small  pin-head-sized  yellowish  white  spots.  The  spleen  is  enlarged 
with  an  excess  of  connective  tissue.  The  organ  feels  much  harder 
than  the  normal. 

The  lungs  show  fibroid  changes  which  are  quite  similar  to  those 
which  occur  in  the  liver.  The  gross  appearance  is  a  lung  of  whitish 
color,  and  to  the  feel  exhibiting  a  marked  loss  of  elasticity. 

The  kidney  changes  are  similar,  but  are  less  characteristic,  be- 
cause the  same  changes  are  noted  in  kidneys  that  are  the  result  of 


142 


SYPHILIS 


other  conditions.  The  lymph  nodes  may  or  may  not  be  involved  in 
a  moderate  degree  of  small  cell  proliferation. 

The  skin  does  not  show  marked  lesions;  in  most  fatal  cases  the 
eruption  has  disappeared.  On  the  other  hand,  there  may  be  evi- 
dences of  superficial  erosions  or  even  a  marked  ulceration.  This  is 
especially  common  about  the  anus  and  the  mouth. 

Bony  changes  are  the  most  typical,  and  are  most  commonly  pres- 
ent. There  are  usually  the  ordinary  evidences  of  inflammatory 
changes  where  the  shaft  and  epiphysis  approximate,  and  these 
changes  are  commonest  in  the  long  bones.  They  may,  however,  occur 


FIG.  53. — HEAD  OF  SYPHILITIC  INFANT,  SHOWING  THE  CHARACTER- 
ISTIC FISSURES  AT  THE  CORNERS  OF  THE  MOUTH  AND  THE 
GENERALLY  SHRIVELED  APPEARANCE. 

in  other  bones.  If  marked  inflammation  has  taken  place  there  are 
some  enlargement  and  swelling  of  the  epiphyseal  junction,  or  there 
may  be  separation.  Late  cases  show  osteophytic  growths  on  the 
shafts  of  the  long  bones.  Gummata  are  common  and  may  be  broken 
down  and  ulcerated. 

Symptoms. — THE  APPEAEAXCE  OF  THE  IXFANT  AT  BIRTH. — The 
appearance  of  the  infant  at  birth  will  depend  upon  several  factors — 
virulence  of  the  infection  and  the  stage  at  which  the  infant  is  born. 
The  infant  may  be  born  without  giving  any  evidences  of  the  discnsr. 
and  it  is  only  after  a  period  of  careful  watching  that  we  are  enabled 
to  detect  evidence  of  the  infection.  If  there  is  a  premature  birth 


CONGENITAL    SYPHILIS 


143 


the  usual  evidences  of  such  immaturity  are  more  or  less  marked.  The 
dusky  color  which  many  of  these  infants  have  is  due  to  the  general 
vascular  tone  being  defective.  Rarely  we  see  the  birth  of  a  pre- 
mature infant  with  well-marked  evidences  of  the  disease  in  the  skin 
and  mucous  membranes. 

If  symptoms  are  present  at  birth  it  indicates  the  severity  of  the 
infection,  and  such  infants  usually  live  but  a  few  days.  The  shriv- 
eled appearance  of  such  an  infant  is  due  to  the  lack  of  fatty  tissue 
in  the  body.  The  skin  lesions  are  more  or  less  tense  bullie  set  upon 


FIG.  54. — HEAD  OF  SYPHILITIC  INFANT,  SHOWING  THE  DESTRUCTION 
OF  THE  HAIR. 


a  deep  red  base  or  surrounded  with  a  dark  or  brownish  red  ring. 
These  bullae  contain  serum,  blood,  or  pus.  In  much  smaller  numbers 
are  seen  less  tense  bulls?,  which  dry  rapidly  into  areas  of  a  dusky  red 
hue,  and  upon  which  the  epidermis  lies  in  a  brown  crust.  Fre- 
quently the  epidermis  slips  from  these  areas,  leaving  moist  and  de- 
nuded surfaces.  The  soles  and  palms  are  the  parts  most  affected, 
although  there  may  be  an  affection  of  other  parts.  In  the  severe 
cases  there  is  usually  a  general  distribution.  There  is,  however, 
one  marked  characteristic:  if  they  appear  at  all  they  are  always 
present  upon  the  palms  and  soles. 


144  SYPHILIS 

SYMPTOMS  SOME  TIME  AFTER  BIRTH. — It  must  be  recalled, 
however,  that  it  is  the  appearance  of  symptoms,  some  time  after  birth 
that  particularly  interests  the  surgeon,  because  this  constitutes  the 
great  majority  of  cases.  There  is  in  congenital  syphilis  no  initial 
lesion  which  corresponds  with  the  chancre  of  the  acquired  form,  and 
the  period  of  incubation  is  subject  to  considerable  latitude.  The 
most  prominent  is  a  persistent  rhinitis.  It  occurs  as  an  early  symp- 
tom, and  for  a  long  time  may  remain  the  single  prominent  evidence 
of  the  disease.  It  varies  in  degree  from  a  slight  stuffiness  of  the 
nose,  without  visible  discharge,  to  a  condition  in  which  there  is  a 
profuse  blood-stained  discharge  continually  discharging  from  the 


FIG.  55. — CONGENITAL  SYPHILIS. 
This  illustration  shows  a  well  marked  eruption  and  the  general  emaciation. 

nostrils  and  interfering  seriously  with  respiration  and  the  act  of 
nursing.  But  whatever  its  degree  it  is  persistent.  We  recall  no  in- 
stance in  which  this  symptom  was  absent,  although  its  evidences  in 
some  few  instances  have  been  but  slight.  During  the  first  few  days 
of  life  we  can  commonly  demonstrate  a  swelling  of  the  nasal  mucous 
membrane,  particularly  that  of  the  inferior  turbinate  bone,  and  this 
occurs  without  any  definite  etiology.  When  the  nose  is  markedly 
involved  there  may  be  later  depression  over  the  bridge,  but  this  is 
not  common.  When  it  does  occur  it  is  usually  very  rapid  in  its 
course. 

Apart  from  this  involvement  of  the  nasal  mucous   membranes 
there  is  usually  no  other  involvement  of  the  mucous  surfaces,  except 


CONGENITAL    SYPHILIS  145 

at  the  regions  about  the  openings  of  the  body,  and  at  these  situations 
fissures  may  appear.  These  fissures  radiate  outward  from  the  mucous 
surface,  and  are  often  deep  enough  to  cause  permanent  scars. 

The  peculiar  eruptions  on  the  skin  usually  appear  soon  after  the 
rhinitis,  and  remain  a  prominent  feature  of  the  disease.  The  most 
common  type  of  skin  lesion  is  an  eruption  in  the  form  of  the  flat, 
disclike,  reddened  areas,  which  later  change  to  a  brownish  tinge,  and 
the  eruption  situated  about  the  thighs,  the  lower  abdomen,  and  but- 
tocks. These  may  also  appear  on  the  face  or  upon  the  soles  and 
palms.  These  may  be  described  variously  as  erythematous,  papular, 
vesicular,  macular,  or  pustular,  but  this  division  is  confusing  and 
unnecessary,  because  the  essential  feature  of  the  eruption  is  the  flat, 
disclike,  circumscribed  character  with  its  peculiar  color.  A  differ- 
ence in  the  intensity  of  the  inflammation  is  really  what  accounts  for 
the  difference  in  the  descriptions  of  the  character  of  the  lesion.  The 
tendency  of  coalescence  is  not  a  marked  feature  of  congenital  syph- 
ilis. On  the  soles  and  the  palms,  which  are  favorite  sites  for  the 
eruption,  the  lesions  are  seen  as  smooth,  shiny,  dark  red  or  brown 
areas,  and  perhaps  an  occasional  bulla.  It  is  only  necessary  to  re- 
member the  main  features  of  the  eruption  to  avoid  being  led  into 
error.  There  is  a  variation  in  intensity  and  in  distribution,  and  this 
variation  has  led  to  the  description  of  almost  innumerable  forms  of 
eruption.  The  main  point  is  to  have  a  clear  idea  of  the  main  fea- 
tures of  the  eruption  of  congenital  syphilis,  and  this  is  of  value  only 
as  it  is  associated  with  other  clinical  features  or  a  history  which  will 
warrant  us  in  making  a  diagnosis. 

After  several  months  it  is  not  unusual  to  find  that  the  hair  be- 
comes very  much  thinned  out,  and  this  may  occur  to  such  an  extent 
that  but  little  hair  is  left.  However,  there  is  never  the  baldness 
which  is  noticeable  in  alopecia  areata.  The  falling  out  begins  gen- 
erally over  the  vertex,  and  this  gives  the  child  the  weird  appearance 
of  still  retaining  a  thicker  fringe  of  hair  about  the  sides  of  the 
head. 

The  nails  are  usually  involved,  and  ordinarily  show  suppuration 
about  the  matrix,  with  subsequent  nail  destruction.  But  preceding 
this  there  may  be  a  simple  arching  of  the  dorsum  of  the  nail. 


146  SYPHILIS 

Splenic  enlargement  is  quite  common.  However,  as  this  is  a 
common  accompaniment  of  many  conditions  in  infancy,  its  value  as 
evidence  is  lessened. 

Not  commonly  there  may  be  hoarseness  or  aphonia,  which  indi- 
cates some  involvement  of  the  mucous  membrane  about  the  larynx. 

In  its  influence  upon  the  nervous  system  the  disease  frequently 
shows  very  early  and  marked  effects.  It  may  so  affect  the  nervous 


FlG.    56. GUMMA    OF   THE    LEG    IN    SYPHILITIC    INFANT. 

system  of  the  fetus  as  to  markedly  affect  its  normal  development. 
This  is  usually  evidenced  by  an  arrest  of  brain  development,  which 
is  the  cause  of  the  many  cases  of  idiocy  which  occur.  The  secondary 
symptoms  which  are  dependent  upon  this  involvement  of  the  in- 
fant's nervous  system  are  of  course  varied  and  innumerable. 

Orchitis  may  occur,  and  the  enlargement  of  the  testes  may  be 
considerable  (two  or  three  times  the  normal  size),  without  tender- 
ness. Occurring  in  early  infancy  this  symptom  is  almost  pathog- 
nomonic. 

The  eye  frequently  shows  changes,  and  there  may  be  a  choroiditis, 
keratitis,  or  corneal  opacity  as  the  result.  A  choroidorctinitis  is  not 
uncommon.  Most  characteristic  of  all  of  the  eye  conditions  is  an  in- 
terstitial keratitis,  which  is  commonly  associated  with  Hutchinsoman 


CONGENITAL    SYPHILIS 


117 


type  of  the  permanent  teeth.  Usually  one  eye  is  affected  for  several 
weeks  before  the  second  one,  and  the  sight  may  be  very  much  dimin- 
ished for  many  weeks  or  even  months. 

Anemia  is  always  present,  and  may  be  very  profound,  but  it  is 
a  common  experience  to  find  this  symptom  persistent  but  moderate  in 
degree  until  many  of  the  other  manifestations  of  the  disease  have 
cleared  up,  and  then  it  is  not  unusual  for  the  anemia  to  be  evidenced 
in  its  most  acute  form.  With  the  anemia  there  is  generally  a  pallor 
to  the  skin,  which  has  a  brownish-yellow  tinge. 

The  affections  of  the 
bones  which  occur  dur- 
ing the  course  of  con- 
genital syphilis  may  well 
be  divided  into  two 
groups:  those  which  ac- 
company the  early  mani- 
festations and  those 
which  accompany  the 
later  ones. 

Acute  epiphysitis  is 
the  most  common  ac- 
companiment of  the 
early  manifestations. 
The  onset  is  almost  al- 
ways very  acute,  so  that 

usually  the  first  thing  noted  is  that  the  infant  is  unable  to  move  the 
limb.  As  a  consequence  two  types  of  motor  disturbance  may  be  no- 
ticed— the  paralytic  and  the  spastic.  There  may  be  inability  to 
move  a  limb  because  of  the  acute  epiphysis  present,  and  it  is  not 
uncommon  to  find  that  this  disability  is  the  first  prominent  feature. 
Usually  it  is  one  or  both  arms  that  are  affected,  and  the  infant 
cries  with  pain  if  the  arms  are  handled.  It  is  of  interest  to  recall 
that  in  specific  bone  disease  of  the  arms  there  is  flaccidity,  while  in 
the  lower  limbs  there  is  contracture  or  spasticity.  The  explanation 
of  this  difference  is  found  in  the  anatomical  relations  of  the  mus- 
culature to  the  joints. 


FlG.    57. GUMMA   OF  THE   EYELID    (BROKEN  DOWN). 


148  SYPHILIS 

With  widespread  involvement  we  may  have  crepitation.  The 
danger  of  mistaking  such  an  occurrence  for  sudden  paralysis  is 
great.  The  slightest  motion  causes  intense  pain  to  the  infant.  This 
symptom,  when  it  occurs,  is  almost  invariably  present  during  the 
first  six  weeks  of  the  infant's  life.  It  is  not  long  before  some  swell- 
ing is  noticed  at  about  the  epiphyseal  line,  being  very  prominent  in 
superficially  placed  bone,  but  less  so  in  a  deeper  situated  one.  Usu- 
ally there  is  a  decided  limitation  to  the  swelling  to  the  end  of  the 

bone,  but  in  rare  and  extreme  cases 
it  may  involve  much  more  of  the 
limb.  Neglected,  this  may  go  on 
to  suppuration. 

Chronic  osteoperiostitis  is  usu- 
ally evidenced  in  the  tibia.  There 
is  a  forward  curve  to  the  anterior 
surface  of  the  bone,  and  the  ap- 
pearance of  the  tibia  is  then  saber- 
like;  it  appears  as  though  the  bone 
was  compressed  at  the  sides,  result- 
ing in  the  forward  curve  or  arch- 
ing. This  arching  is  only  apparent, 
however,  for  there  is  no  actual 

FIG.    58.-SABER-LIKE     APPEARANCE      OF     cllrye    Qf    ^    ghaft    Qf    ^    ^  th(J 

THE  LEG  WHICH  is  SOMETIMES  OB- 
SERVED IN  CONGENITAL  SYPHILIS,      appearance   being   entirely   due   to 

new-formed  tissue  on  the  anterior 

surface.  The  new  bone  deposit  is  the  result  of  a  specific  periostitis, 
and  therefore  in  the  early  stages  it  is  accompanied  by  pain  which 
is  worse  at  night.  With  the  occurrence  of  visible  thickening  the 
pain  becomes  less  and  less  of  a  factor.  Atypical  cases  may  give  no 
evidences  of  pain  except  upon  handling  of  the  infant. 

The  changes  in  the  skull  may  be  manifested  in  several  ways: 
there  may  be  changes  which  are  not  distinguishable  from  those  due 
to  rachitis ;  there  may  be  abnormal  protuberance  of  the  frontal  and 
parietal  eminences,  with  early  ossification  of  the  sutures,  or  hydro- 
cephalus.  The  usual  form  is  that  of  a  gummatous  periostitis.  These 
gummata  are  half-spherical,  limited  swellings,  which  are  more  or 


CONGENITAL    SYPHILIS 


149 


less  painful.  At  first  they  appear  to  be  solid,  hut  later  there  is  a 
somewhat  distinct  fluctuation  felt,  and  at  the  same  time  they  become 
more  or  less  adherent  to  the  skin. 

Dactylitis  is  not  so  common  as  epiphysitis,  but  when  it  occurs  it 
resembles  somewhat  closely  that  due  to  tuberculosis.  The  fingers 
are  more  often  affected  than  the  toes.  Fusiform  swell  ins:  of  the 

O 

proximal  phalanx  is  the  usual  lesion. 

The  teeth  are  erupted  late,  and  show  early  decay.  The  changes 
are  many;  all  of  the  teeth,  or  only  the  middle  incisors,  may  be  ab- 
normally small,  with  resultant  slits  between  the  teeth.  In  other  in- 


FIG.  59. — HUTCHINSON'S  TEETH.     (Beers.) 

stances  they  are  covered  with  a  false  enamel,  which  rapidly  crumbles, 
allowing  the  teeth  to  decay  or  rot.  On  the  surfaces  there  are  fre- 
quently calciform  and  fusiform  striated  erosions,  which  are  some- 
times single,  forming  a  groove.  Such  teeth  occur  most  often  in  the 
congenital  type  of  the  disease,  but  are  not  limited  to  this  form,  or 
even  to  syphilis,  'so  that  they  are  to  be  considered  only  as  corrobora- 
tive evidence.  Particularly  characteristic  of  syphilis  is  the  presence 
of  Hutchinson's  teeth;  these  are  characterized  by  the  semilunar 
notching  of  the  free  edge  of  the  two  upper  middle  incisors.  Besides 
this,  the  teeth  are  short,  narrow,  and  with  rounded  corners. 


150  SYPHILIS 

Hemorrhagic  effusions  in  all  situations  are  common  in  the  young 
infant,  so  that  it  is  not  uncommon  to  find  that,  under  the  influence 
of  prolonged  or  difficult  labor,  even  intracranial  or  subpericranial 
effusions  occur.  The  evidences  of  the  interference  with  nutrition 
may  become  very  marked,  so  that  the  infant  may  die  of  wasting,  or 
remain  so  emaciated  and  weakened  that  some  slight  intercurrent  dis- 
ease is  sufficient  to  cause  death. 

An  irregular  type  of  temperature  is  common  to  congenital  syph- 
ilis. Often  the  superficial  lymphatic  glands  are  enlarged  so  that 
they  are  palpable,  but  the  enlargements  show  no  distinctive  features, 
being  similar  to  gland  involvement  in  other  conditions.  However, 
this  adenitis  is  more  apt  to  occur  as  a  late  manifestation  rather  than 
an  early  one. 

One  of  the  latest  symptoms  to  appear  is  an  affection  of  the  ears, 
which  is  quite  characteristic  of  congenital  syphilis  and  which  is  de- 
pendent upon  mild  but  persistent  inflammation  of  the  middle  ear. 
This  symptom  is  deafness,  which  is  rapid  in  its  course,  and,  in  fact, 
so  rapid  that  complete  deafness  is  common  after  a  few  weeks  of 
the  onset. 

Diagnosis. — There  are  several  factors  which  must  be  considered 
in  this  particular :  The  family  history,  the  type  of  the  disease,  the 
appearance  of  the  infant  at  birth,  and  the  appearance  of  symptoms 
some  time  after  birth. 

FAMILY  HISTORY. — This  is  most  important  and  yet  difficult  to 
obtain,  unless  the  examiner  has  a  clearcut  idea  of  what  he  should 
elicit  and  has  the  ability  to  do  it  skilfully.  Because  of  the  attitude 
which  the  laity  assume  in  regard  to  the  matter,  the  question  "Have 
any  of  the  family  ever  had  syphilis?"  should  never  be  asked.  A 
denial  means  nothing,  and  by  placing  the  questioned  one  upon  guard 
it  detracts  from  the  honesty  and  value  of  subsequent  answers  to 
other  questions.  It  is  far  better  and  much  more  certain  to  obtain 
a  history  of  events  which  will  establish  a  strong  presumptive  evidence 
as  to  the  existence  of  the  disease.  The  several  events  to  be  considered 
are  these: 

(a)   The  tendency  of  the  children  of  a  given  family  to  suffer 
from  unaccountable   anemias   and  malnutrition  during  the  earlier 


CONGENITAL    SYPHILIS  151 

periods  of  life,  despite  the  fact  that  the  hygienic  surroundings  and 
the  dietetic  care  are  both  excellent. 

(b)  The  occurrence  of  anomalous  types  of  disease  in  two  or 
more  children  of  the  same  family,  or  the  unusual  course  of  a  disease 
under  similar  circumstances. 

(c)  Tardy  development  without  a  recognized  cause,  or  occurring 
as  the  result  of  a  recognized  etiology,  but  out  of  all  proportion  to 
that  cause  and  occurring  in  two  or  more  children  of  the  same  family. 

(d)  The   occurrence   of   a   rachitic  type   of   skull   without    the 
other  evidences  of  rachitis  being  proportionately  marked. 

(e)  History  of  the  disease,  direct  or  presumptive,  in  one  or  both 
parents. 

(f  )  A  history  of  the  abortive  habit  in  the  mother  without  definite 
cause. 

The  death  of  the  fetus  may  occur  at  any  period  of  intrauterine 
life.  But  the  most  common  occurrence  of  the  event  is  between  the 
fourth  and  the  seventh  month.  In  those  pregnancies  which  are 
terminated  early  (first  five  months)  the  fetus  may  show  no  evidences 
of  the  disease  which  are  clearly  demonstrable.  Histological  sections 
may  be  compared  with  those  of  the  normal  fetus,  but  this  is  not  always 
feasible.  During  the  last  four  months  of  pregnancy,  if  the  fetus  is 
expelled  the  evidences  of  disease  are  usually  unmistakable.  This  is 
particularly  true  of  changes  in  the  placenta.  Not  infrequently  the 
placental  changes  cause  a  phlebitis  of  the  cord  (veins),  and  the 
premature  expulsion  and  death  of  the  fetus  are  found  in  hydramnios. 

The  gross  appearance  of  the  specific  placenta  is  usually  as  fol- 
lows: It  is  larger  and  heavier  than  normal  and  its  lobes  are  de- 
formed. It  is  pale  and  often  yellowish  in  hue,  with  much  thickened 
and  hardened  cord.  The  types  of  the  disease  (see  page  141)  and  the 
appearance  of  the  infant  at  birth  (see  page  142)  have  already  been 
referred  to  and  need  not  be  repeated  at  this  point. 

It  is  now  very  generally  believed  that  the  Spirochaeta  pallid  a  is 
the  cause  of  syphilis.  Of  course,  most  of  the  work  along  this  line  has 
been  among  adults  and  in  the  acquired  form  of  the  disease.  But 
there  is  enough  evidence  to  warrant  us  in  conceding  that  the  cause 
of  syphilis  has  been  discovered,  although  the  technique  necessary  to 


COLLlietE   OF 


I    I    !-•     .-*    I  — 


152  SYPHILIS 

demonstrate  this  readily  is  undergoing  rapid  change  and  advance- 
ment. 

WASSERMANN  REACTION.  —  There  is  every  reason  to  believe  that 
in  congenital  syphilis  the  Wassermann  reaction  will  prove  and  is 
proving  as  reliable  and  valuable  as  it  does  in  the  acquired  form. 
It  is  freely  admitted  by  the  investigators  that  its  value  is  as  propor- 
tionately great  in  the  diagnosis  of  the  late  hereditary  type  as  in 
the  acquired.  So  far  as  we  have  had  any  experience  with  its  value 
in  early  congenital  cases  it  has  been  confirmatory,  but  the  experience 
along  this  line  has  been  too  limited  to  give  it  much  value.  With 
the  marked  improvements  which  II.  Noguchi,  of  the  Rockefeller  In- 
stitute, has  made  in  the  technique  there  is  a  stimulus  to  a  wider  use 
of  the  reaction.  It  involves  but  little  effort  upon  the  part  of  the 
attending  physician.  Ten  or  fifteen  good  sized  drops  of  blood  from 
the  ear  passed  into  a  sterile  tube  (similar  to  that  used  for  the  swabs 
in  diphtheria  cultures)  and  tightly  sealed  are  the  material  necessary. 
If  this  is  kept  cool,  the  pathologist  has  a  workable  material,  and  it 
will  keep  for  forty-eight  hours.  Personally  we  feel  that  this  method 
of  examination  is  on  the  same  plane  as  many  of  our  other  methods 
(as,  for  instance,  diphtheria  cultures),  a  positive  reaction  from  a 
case  accompanied  by  suspicious  symptoms  means  the  presence  of 
syphilis;  a  negative  reaction  means  nothing. 

Prognosis.  —  It  must  be  remembered  that  congenital  syphilis  is  a 
much  more  fatal  disease  than  the  acquired  form  of  adults.  Malnu- 
trition is  the  common  cause  of  death,  the  vitality  of  the  child  being 
so  markedly  affected  that  the  occurrence  of  some  slight  intercurrent 
disease  often  determines  the  issue.  The  earlier  the  symptoms  appear, 
the  worse  the  prognosis.  Even  allowing  that  the  infection  is  mild 
and  the  treatment  adequate,  syphilitic  infants  usually  do  not  develop 
normally,  and,  therefore,  even  at  its  best,  the  prognosis  must  be 
guarded  as  to  the  future  physical  and  mental  vigor  of  the  child. 

Treatment.  —  If  a  woman  should  become  pregnant  by  a  man  known 
to  be  suffering  from  syphilis,  or  if  she  herself  be  a  syphilitic  and  be- 
come pregnant,  an  antisyphilitic  treatment  should  be  rigorously  in- 
stituted as  early  in  the  pregnancy  as  possible,  and  must  be  con- 
tinued throughout  the  whole  period.  The  treatment  should  be  that 


CONGENITAL    SYPHILIS  153 

which  has  been  found  adequate  in  adult  cases.  The  infant  horn  of 
such  a  mother  should  have  every  advantage  of  breast  feeding  and, 
during  the  lactation  period,  the  treatment  of  the  mother  should  be 
continued. 

The  best  means  of  treating  the  affected  infant  is  by  the  use  of 
mercury,  internally,  hypodermatically,  or  by  inunction.  The  hypo- 
dermatic method  has  serious  objections  which  are  at  once  obvious, 
and  therefore  its  use  is  limited.  In  institutional  work  the  inunctions 
are  the  preferable  method  because  of  the  certainty  with  which  they 
act.  But  in  our  private  practice  the  benefits  of  this  method  are 
diminished  by  the  inability  to  hide  the  fact  that  the  mercury  is 
being  used  and  the  staining  of  the  skin,  which  attracts  unfavorable 
attention  to  the  infant.  Inunctions  advertise  the  disease. 

The  inunction  is  employed  by  the  thorough  rubbing  into  the 
skin  of  mercurial  ointment.  The  rubbing  must  be  done  once  daily 
and  continued  for  ten  minutes.  Different  areas  are  selected  for 
each  day's  application,  and  the  best  places  are  the  inner  aspect  of 
the  thighs,  the  abdomen,  the  axilla,  or  the  chest.  We  have  found  no 
advantage  in  the  use  of  inunctions  over  the  internal  administration 
of  the  drug.  Secrecy,  cleanliness,  and  comfort  are  all  conserved 
by  the  latter  method. 

As  the  symptoms  usually  appear  some  time  during  the  first  two 
months  of  life,  the  infant  may  be  given  either  of  the  following, 
night  and  morning,  after  a  feeding: 

Bichlorid  of  mercury,  1-200  grain. 
Gray  powder,   1-2  grain. 
Calomel,  1-8  grain. 

After  the  selection  is  made,  the  drug  is  continued  for  one  week, 
and  then  on  every  alternate  day  an  extra  dose  (the  drug  administered 
three  times  daily  in  place  of  twice)  is  given,  until  a  decided  improve- 
ment has  been  noted.  After  the  establishment  of  a  steady  improve- 
ment the  administration  may  be  reduced  again  to  twice  daily,  dis- 
regarding the  increased  dose  on  the  alternate  days.  However,  if 
improvement  is  not  rapid  enough  or  continued,  the  dose  may  be 
increased  for  a  time  to  four  or  five  times  daily,  but  with  this  increase 
there  will  be  a  tendencv  to  looseness  of  the  bowels  with  green  stools, 


154  SYPHILIS 

so  that  a  combination  with  some  controlling  drug  may  be  necessary. 

Usually  the  first  indication  of  improvement  is  the  fading  of  the 
cutaneous  rash,  which  as  it  clears  leaves  the  characteristic  stain- 
ing which  persists  often  for  weeks.  Almost  coincident  with  the  dis- 
appearance of  the  rash,  the  other  symptoms  begin  to  subside,  although 
the  splenic  and  liver  enlargement  may  persist  for  several  weeks. 
Soon  there  are  gains  in  weight  and  other  evidences  that  the  nutri- 
tion of  the  infant  is  undergoing  a  decided  change  for  the  better. 

Not  infrequently  cases  are  seen  in  which  the  vital  forces  of  the 
infant  and  its  recuperative  powers  are  so  low  that  treatment  is  of 
little  avail,  because  before  its  influence  is  adequately  brought  to 
bear  upon  the  disease  the  infant  is  exhausted.  Still  more  rarely 
treatment  fails  to  act  as  promptly  and  efficiently  as  is  usual  and 
the  infant  slowly  dies  from  inanition. 

Not  infrequently  a  "cured"  case  of  congenital  syphilis  has  a 
return  of  symptoms  after  several  months  or  years,  and  therefore  it  is 
necessary,  in  considering  the  treatment  of  the  disease,  to  consider 
what  constitutes  safety  in  the  cessation  of  treatment.  Abundant 
clinical  experience  would  seem  to  strongly  indicate  that  the  "cured" 
case  should  receive  treatment  at  least  one  month  out  of  every  four, 
and  that,  in  the  presence  of  any  disease  affecting  nutrition,  the  usual 
remedies  should  be  combined  with  antisyphilitic  treatment.  lodids 
are  not  usually  necessary  in  these  cases,  and  it  has  been  taught  that, 
as  the  earlier  symptoms  are  "secondaries,"  their  use  is  never  neces- 
sary. This  has  explained  the  failure  to  get  results  in  some  of  the 
cases  I  have  seen  in  consultation.  There  are  times,  even  during 
infancy,  when  the  administration  of  the  iodids  is  just  as  necessary 
and  as  beneficial  as  in  later  childhood,  when  "tertiary"  symptoms 
are  more  common. 

Gummata,  the  various  bone  lesions,  and  particularly  acute  epi- 
physitis  are  much  more  amenable  to  treatment  by  the  iodids  com- 
bined with  the  mercury  than  by  the  mercury  alone. 

The  inherent  tendency  to  frequent  gastrointestinal  disturbances, 
to  failures  of  assimilation,  and  to  nutritional  faults  must  be  remem- 
bered and  everything  done  to  surround  the  syphilitic  infant  with 
the  best  that  scientific  feeding  and  hygiene  can  afford. 


STATUS    LYMPHATICUS  155 

The  use  of  salvarsan  promises  good  results  in  many  cases,  but 
at  the  present  time  the  splendid  results  reported  by  some  observers 
in  congenital  syphilis  and  the  failures  reported  by  others  leave 
the  matter  somewhat  in  doubt.  It  is  one  of  those  methods  of  treat- 
ment which  will  have  to  be  tried  in  several  thousand  cases  and  the 
remoter  effects  carefully  observed  before  we  can  accept  it  as  a  routine 
treatment,  such  as  is  done  with  mercury  or  the  iodids  to-day.  In 
the  meantime  it  may  be  administered  in  selected  instances  with 
the  promise  of  good  results. 


CHAPTEE  XXV 

STATUS  LYMPHATICUS 

This  term  should  only  be  applied  to  that  very  definite  pathological 
condition  which  is  associated  with  a  clinical  picture  that  is  far 
from  constant  or  in  any  manner  characteristic,  but  which  is  definite 
enough  to  distinguish  it  from  "lymphatism,"  with  which  it  is  con- 
stantly confused. 

"Lymphatism,"  or  the  tendency  to  hyperplasia  of  the  lymph  nodes 
which  exists  in  all  children  but  which  is  so  characteristic  in  some 
children  as  to  be  reasonably  considered  as  a  diathesis,  is  entirely 
distinct  from  status  lymphaticus.  There  are  instances  when  the 
one  seems  to  approximate  very  closely  the  other,  but,  on  the  whole, 
there  is  usually  enough  about  the  several  features  of  both  conditions 
to  clinically  separate  them. 

Status  lymphaticus  may  occur  at  any  age,  but  is  most  often  ob- 
served between  the  sixth  and  the  twelfth  months. 

Pathology. — Undoubtedly  the  condition  is  much  more  common 
than  we  have  been  led  to  suppose,  because  not  all  cases  end  fatally. 
Pathological  enlargement  of  the  thymus  is  not  infrequent.  As  re- 
gards the  normal  size  and  condition  of  the  thymus,  the  observations 
of  Bovaird  and  Kicoll  are  instructive.  These  observers  took  the 
weight  of  the  thymus  in  nearly  500  consecutive  autopsies  of  children 
under  the  age  of  five  years  and  found  that  the  weight  was  greatest 


156  STATUS  LYMPHATICUS 

at  birth,  and  that  thereafter,  until  the  end  of  the  fifth  year,  the 
weight  did  not  materially  increase  or  diminish.  The  birth  weight 
was  averaged  at  7.7  grams. 

When  glands  weighing  over  10  grams  were  excluded  this  average 
of  7.7  grams  was  reduced  to  6.5  grams.  The  very  rapid  decrease 
in  weight  which  occurred  immediately  after  birth  made  the  average 
weight  of  the  gland  for  the  period  of  childhood  up  to  five  years 
between  3  and  4  grams.  Anything  over  10  grams  was  considered 
by  them  as  abnormal. 

In  the  status  lymphaticus  the  thymus  may  be  many  times  larger 
than  normal,  and  its  increase  in  weight  in  proportion.  Examined 
under  the  microscope,  such  an  enlarged  gland  does  not  exhibit  any 
characteristic  changes  except  those  due  to  the  hyperplasia. 

There  is  associated  with  this  thymus  enlargement  hyperplasia 
of  the  lymphoid  tissue  throughout  the  body,  so  that  we  observe 
enlargement  of  the  lymph  nodes  of  the  tracheobronchial  region,  of 
Peyer's  patches  and  the  solitary  follicles  of  the  intestine,  of  the 
lymphoid  tissues  of  the  pharnyx,  and,  in  fact,  of  all  portions  of 
the  body.  Even  the  spleen  may  be  enlarged  and  all  other  causes  of 
splenic  enlargement  can  be  excluded. 

Symptoms. — The  condition  is  of  special  interest  because  in  early 
infancy  it  may  be  the  explanation  of  the  cause  of  death  which  takes 
place  under  the  most  trivial  circumstances,  or  occurs  without  any 
appreciable  cause.  Such  infants  are  frequently  found  dead  in  their 
cribs. 

The  cases  which  are  of  greatest  interest  and  concern  to  the 
surgeon,  however,  are  those  in  which  the  child  lives  to  a  considerable 
age  and  throughout  that  period  gives  little  or  no  clew  to  the  condi- 
tion present.  Then,  as  the  result  of  some  slight  accident  or  a  minor 
surgical  procedure,  or  even  the  administration  of  an  anesthetic  in 
anticipation  of  one,  the  symptoms  are  brought  prominently  forward. 

The  occurrence  of  the  symptoms  is  usually  so  suddenly  followed 
by  death  that  there  is  no  chance  for  treatment.  There  is  nothing 
about  the  child  during  life  that  is  very  suggestive,  and  most  often 
the  history  is  that  a  child  who  has  been  previously  considered  in 
perfect  health  is  suddenly  seized  with  convulsions  and  a  high  tern- 


DIAGNOSIS  157 

perature  and  some  indefinite  asphyxial  feature  which  does  not  cor- 
respond to  anything  that  may  be  found  in  the  chest. 

The  temperature  and  convulsions  are  usually  persistent,  with 
death  occurring  within  one  to  thirty-six  hours.  In  other  instances 
the  asphyxial  element  is  the  predominant  one  and  may  be  quite 
spasmodic  but  without  association  with  general  convulsions.  In  this 
type  the  measures  of  relief  usually  bring  the  child  out  of  the  first 
attack,  but  this  is  followed  in  a  few  hours  by  a  more  severe  one,  and, 
after  .several  such  increasing  ones,  death  occurs.  In  this  form  the 
temperature  is  not  usually  so  high  as  in  the  other.  Symptoms 
similar  to  these,  but  in  many  degrees  of  lessened  severity,  may  sug- 
gest the  true  condition  and  result  in  recovery. 

There  are  many  theories  in  regard  to  the  cause  of  the  symptoms, 
but  we  are  very  uncertain  as  to  their  real  cause.  Pressure  of  the 
enlarged  thymus  upon  the  lungs,  the  trachea,  the  pneumogastric 
nerves,  and  upon  the  heart  would  seem  to  be  a  plausible  explanation 
of  the  asphyxial  features  of  certain  cases,  but  it  fails  to  explain 
most  cases. 

The  largest  number  of  cases  would  come  under  that  group  in 
which  there  is  nothing  in  the  condition  of  the  child  or  about  the 
symptomatology  of  the  attack  which  would  associate  it  with  the 
status  lymphaticus,  and  yet  when  the  child  becomes  the  victim  of 
an  apparently  very  trivial  inflammation  or  injury  there  is  a  very 
great  and  disproportionate  resistance  to  injuries  and  inflammations 
in  particular  and  to  all  disease  in  general.  When  autopsies  have 
been  performed  upon  children  showing  this  characteristic  during 
life,  it  has  very  commonly  been  found  that  the  status  lymphaticus 
was  the  only  plausible  cause. 

Diagnosis.- — It  will  be  observed  from  this  that  the  diagnosis  is 
always  very  uncertain  and  that  we  cannot  be  anything  more  than 
suspicious  of  the  condition  during  the  life  of  the  child. 

However,  this  suspicion  may  be  very  strong  and  rest  upon  the 
history  of  the  child  suffering  severe  shock  which  is  out  of  all  pro- 
portion to  any  particular  injury  received.  It  is  common  to  observe 
children  who,  from  slight  falls  or  injuries,  suffer  so  severely  and 
remain  prostrated  so  long  that  we  know  that  something  unusual 


158  STATUS  LYMPHAT1CUS 

exists  about  that  particular  child.  A  carefully  taken  surgical  his- 
tory always  reveals  this  point  and  the  surgeon  is  thus  amply  warned 
that  under  even  the  slighter  surgical  procedures  that  child  will  give 
evidences  of  most  serious  shock. 

We  have  for  a  long  time  been  suspicious  that  some  degree  of 
status  lymphaticus  underlies  this,  although  it  cannot  be  definitely 
proved.  For  practical  purposes,  at  least,  the  history  is  sufficient 
to  make  the  surgeon  cautious  in  undertaking  any  surgical  procedure. 


SECTION  VI 

INFECTIOUS  DISEASES 

CHAPTER  XXVI 

ADENITIS 

SIMPLE   ACUTE   ADENITIS 

Acute  enlargement  of  the  lymphatic  glands  is  the  usual  accom- 
paniment of  the  various  acute  infectious  diseases,  and,  in  this  particu- 
lar, the  enlargement  is  not  an  accidental  one,  for  there  exists  a  well- 
established  connection  between  the  location  and  the  extent  of  the 
adenitis  and  the  disease  with  which  it  is  associated. 

Such  enlargements  are  practically  certain  to  occur  when  the 
infectious  process  causing  them  is  a  severe  one,  or  is  long  in  duration. 
It  is  not  uncommon  to  find  that  the  primary  cause  of  an  adenitis 
is  so  apparently  minor  or  has  occurred  at  such  a  remote  period  that 
its  influence  has  been  overlooked  or  forgotten,  and  under  such  cir- 
cumstances the  adenitis  itself  assumes  the  appearance  of  a  primary 
condition. 

During  the  period  of  early  life,  and  particularly  during  the  first 
two  years,  adenitis  is  most  common  and  there  is  good  reason  for  this. 
The  fetus  in  utero  is  protected  to  a  very  considerable  degree  by  the 
natural  and  the  acquired  immunities  of  the  mother,  but  immediately 
after  birth  it  is  suddenly  exposed  to  many  and  varied  pathogenic 
influences.  Thus  the  infant  is  early  forced  to  depend  largely  upon 
its  own  powers  of  immunity,  which  are  transmitted  to  him  by  his 
mother,  and  when  these  fail  him  he  must  necessarily  fall  back  upon 
the  protection  offered  largely  by  his  own  lymphoid  tissue  and  glands. 

Etiology. — Acute  adenitis  occurs  in  children  of  all  ages,  but  par- 
ticularly in  those  of  tender  years  in  the  course  of  any  one  of  the 

139 


160  ADENITIS 

acute  infections.  Suppuration  is  not  a  common  occurrence,  except 
during  the  course  of  scarlet  fever  or  unless  the  child  is  very  young 
or  is  suffering  from  some  severe  nutritional  fault.  This  rather  ex- 
treme susceptibility  of  infants  has  already  been  explained.  Given 
a  child  with  a  severe  or  a  prolonged  fault  of  nutrition  and  the  slight- 
est acute  infectious  process  is  practically  certain  to  result  in  an  acute 
adenitis.  One  very  prolific  cause  of  suppuration  is  overtreatment 
of  the  swellings,  particularly  by  local  applications  that  prove  in  time 
more  or  less  irritating  to  the  tender  skin  of  the  child.  Such  measures 
invite  rather  than  limit  pathogenic  infection. 

Any  gland  in  the  body  may  become  the  site  of  an  adenitis  and 
this  depends  upon  the  location  and  extent  of  the  primary  factor. 

A  reference  to  the  chart  on  pages  163-164:  will  help  to  elucidate 
this  point. 

The  Lesions.  — The  changes  which  take  place  in  the  glands  are 
an  acute  congestion  with  subsequent  swelling,  edema,  and  an  active 
hyperplasia  of  the  lymphoid  elements.  Resolution  is  the  rule  in 
older  children,  unless  the  infection  is  unusually  severe  or  the  child's 
system  is  rendered  lower  in  resistance  by  other  factors.  During 
infancy  there  is  a  marked  tendency  toward  suppurative  changes  even 
when  the  primary  infection  is  a  mild  one. 

If  suppuration  occurs,  inflammation  of  the  surrounding  cellular 
tissue  is  added  to  the  previous  lesions. 

The  lesions  are  usually  unilateral,  or  if  bilateral  then  one  side 
is  almost  invariably  much  worse  than  the  other.  Suppuration  is 
practically  always  unilateral  and  starts  in  a  single  gland,  but  may 
extend  subsequently  to  others. 

Symptomatology. — The  most  typical  cases  are  those  which  occur 
during  the  first  two  years  of  life.  In  them  there  are  present  the 
symptoms  of  the  primary  causative  factor  (which  may  be  a  nasal  or 
nasopharyngeal  catarrh,  or  inflammation  somewhere  about  the  mouth 
or  the  ear)  plus  an  enlargement  occurring  as  a  group  of  nodules 
which  are  freely  movable  and  definitely  outlined. 

The  swelling  is  neither  rapid  in  its  onset  nor  great  in  its  extent, 
and,  as  a  rule,  persists  only  for  a  short  period  after  the  primary  dis- 
ease or  causative  factor  has  subsided.  The  glands  most  commonly 


SIMPLE    ACUTE    ADENITIS 


affected  are  the  deep  cervical.  However,  in  those  few  instances 
in  which  there  is  an  early  and  marked  inflammation,  of  the  peri- 
glandular  cellular  tissue,  there  is  a  much  more  rapid  swelling  and 
the  glands  cannot  be  made  out  so  definitely.  With  this  latter  type 
there  are  added  considerable  pain,  heat,  and  tenderness  about  the 
parts. 

When  suppuration  supervenes  it  is  usually  during  the  latter  part 
of  the  second  week  of  the  swelling,  although  the  instances  in  which 
it  occurs  much  later  than  this  are  by  no  means  uncommon.  There 


FIG.  60. — SALIVARY  CALCULI  REMOTELY 
SIMULATING  ADENITIS. 


FIG.  61. — FRONT  VIEW  OF  SAME  CASE  AS 
FIGURE  60. 


is  a  slight  elevation  of  the  temperature  in  most  instances,  and  this 
fluctuates  during  the  whole  course  of  the  adenitis.  Any  consid- 
erable rise  in  the  temperature,  or  a  prolongation  of  its  course,  should 
arouse  the  suspicion  of  suppuration. 

In  those  children  who  are  rachitic,  or  who  exhibit  the  evidences 
of  some  marked  nutritional  fault,  the  general  symptoms  are  all  apt 
to  be  emphasized  and  may  be  quite  severe,  with  early  prostration. 
When  this  occurs  it  may,  for  a  time,  leave  one  in  doubt  as  to  the 
possibility  of  the  adenitis  being  entirely  responsible. 

Suppuration  is  usually  not  difficult  of  management  because  there 
is  a  marked  tendency  toward  rapid  resolution  after  a  prompt  and 


162  ADENITIS 

adequate  incision.  Most  of  the  cases  that  do  not  quickly  respond 
are  those  in  which  the  incision  has  been  inadequate  to  the  require- 
ments of  the  case,  or  has  been  too  long  delayed.  The  formation  of 
a  sinus  is  very  rare. 

It  is  uncommon  that  the  infection  extends  from  one  gland  to 
another  and  that  multiple  abscesses  are  encountered.  It  is  a  peculiar 
fact  that  the  non-suppurative  cases  exhibit  much  more  swelling  than 
do  the  suppurative,  but,  upon  the  other  hand,  they  are  also  more 
clearly  defined. 

The  usual  course  extends  over  a  period  of  from  four  to  eight 
weeks,  and  not  infrequently  some  of  the  enlargement  persists  for 
several  months  without  causing  any  appreciable  discomfort  or  in- 
convenience. Many  children  exhibit  an  apparent  susceptibility  to 
adenitis  and  in  these  chronic  enlargement  is  the  rule. 

Diagnosis. — Excepting  the  acute  infectious  diseases  and  the  occa- 
sional local  causes  of  adenitis  (as  caries  of  the  teeth,  stomatitis,  ec- 
zema of  the  scalp,  pediculosis  capitis,  etc.)  acute  simple  adenitis  is 
a  disease  largely  of  infancy.  This  fact  renders  the  diagnosis  much 
more  certain.  One  of  the  most  common  errors  is  in  mistaking  an 
ordinary  attack  of  "mumps"  for  an  acute  simple  adenitis.  This  is 
particularly  perplexing  in  those  instances  in  which  the  parotiditis 
begins  (that  is,  as  far  as  the  swellings  are  concerned)  as  an  enlarge- 
ment of  the  submaxillary  or  sublingual  glands.  In  all  such  instances 
it  is  necessary  to  search  for  the  various  causative  factors  for,  with 
any  considerable  degree  of  enlargement  dependent  upon  an  acute 
adenitis,  these  would  be  evident. 

The  danger  of  mistaking  tuberculous  glands  is  not  great,  because 
in  acute  adenitis  we  are  dealing  with  an  entirely  acute  process  which 
has"  practically  nothing  in  its  symptomatology  which  is  in  common 
with  the  slow  and  progressive  suppuration  which  is  observed  in 
later  childhood.  In  addition  the  glands  do  not  adhere  to  each  other 
or  to  the  skin  or  the  surrounding  tissues  as  they  do  in  tuberculous 
adenitis. 

Treatment. — Recalling  the  common  occurrence  of  an  acute  simple 
adenitis  during  childhood,  and  particularly  during  the  period  of  in- 
fancy, the  prophylactic  demands  are  that  the  greatest  amount  of  care 


SIMPLE    ACUTE    ADENITIS 


must  be  given  to  the  toilet  of  the  mucous  membranes  whenever 
there  is  an  existing  catarrh,  and  that  care  should  not  be  relaxed  until 
a  considerable  period  after  the 
subsidence  of  all  acute  symp- 
toms. During  the  course  of  the 
infectious  diseases  the  authors 
have  found  that  the  usual  mouth 
washes  are  not  entirely  efficient 
in  children,  no  matter  how  care- 
fully they  are  applied,  and,  in 
such  instances,  the  regular  use  of 
chewing-gum  has  a  most  salutary 
action  upon  the  cleanliness  of  the 
mouth. 

When  acute  inflammation 
has  occurred  relief  may  be  ob- 
tained most  surely  by  the  appli- 
cation of  an  ice-bag.  There  is 
often  a  very  vigorous  objection 
to  this  procedure  by  the  child 
and,  in  such  instances,  very  hot  FlG.  62.— LOCATION  OF  THE  PRINCIPAL 
applications  may  have  to  be  Sub-  LYMPHATIC  GLANDS  OF  THE  NECK. 

Stituted.       Pain    is    markedly    re-  (For    explanation    of  the  diagnostic  signifi- 
-,.          i     •       ,1  •  ,     •,     •  cance  of  their    acute    enlargement,  see 

lieved  in  this  manner,   but  it  is 


very  doubtful  whether  either  of 
these  measures  have  any  influ- 
ence in  preventing  or  limiting 
suppuration. 

Local  applications  of  the  va- 
rious ointments  and  pastes  of 
various  strength — iodin,  and  so 
forth — have  failed  signally  in 
our  hands.  Such  cases  go  on  to 
suppuration  in  spite  of  anything 
which  is  applied  externally;  in 
fact,  it  has  been  our  experience 


numerals  below.)  1.  Diseases  of  the 
ear  (especially  eruptions) ;  eruptions 
about  the  face;  and  occasionally  during 
parotiditis.  2.  Mastoiditis  and  infec- 
tions and  eruptions  affecting  the  scalp. 
3.  Infections  of  the  chin,  the  tongue, 
and  the  lower  lip.  4.  Infections  of  the 
mouth  and  teeth,  stomatitis,  rubeola, 
and  rubella.  5.  Infections  of  the  tonsils 
in  the  mild  attacks  of  scarlet  fever  and 
at  first  in  variola.  In  severe  scarlet 
fever  5,  6,  7  and  8  may  be  much  affected. 
6.  Pharyngeal  infections  and  inflam- 
mations, therefore  in  retropharyngeal 
lymphadenitis.  Also  in  severe  scarlet 
fever  and  in  rubeola.  7.  Infections  of 
the  scalp  and  severe  scarlet  fever.  8. 
Infections  of  the  scalp  and  severe  scarlet 
fever.  (During  the  course  of  diph- 
theria, 4,  5,  6,  7  and  8  may  become 
prominently  enlarged,  so  that  the  whole 
neck  appears  badly  swollen  and  tender.) 


164 


ADENITIS 


that  many  of  the  recommended  local  applications  tend  to  bring  about, 
rather  than  to  limit,  suppuration.  Certain  it  is  that,  if  they  cause 

even  minute  breaks  in  the  skin, 
they  favor  the  introduction  of  path- 
ogenic organisms. 

We  are  convinced  that  a  careful 
toilet  of  the  affected  and  the  sur- 
rounding parts  and  the  prevention 
of  injury  to  the  glands  (injury 
through  continued  pressure,  con- 
stricture,  rubbing,  etc.)  will  accom- 
plish all  that  is  possible  in  the  lim- 
itation and  prevention .  of  suppura- 
tion. 

When  suppuration  takes  place 
incision  may  be  deferred  until 
pointing  of  the  abscess  has  occurred, 
for  then  we  are  reasonably  certain 
that  the  refilling  of  the  cavity  can 
be  prevented. 

A  simple  but  adequate  incision 
is  all  that  is  required  in  most  cases, 
but,  if  there  is  an  abundance  of 
broken  down  tissue,  the  cavity  may 
require  curetting.  Such  a  pro- 
cedure practically  insures  prompt 
healing.  In  those  instances  in 
which  healing  is  delayed  the  cause 
may  almost  always  be  found  in  an 
inadequate  incision,  which  has  not 
allowed  of  a  complete  emptying  of 
the  cavity. 

The  removal  of  the  primary 
cause  is  of  necessity  indicated  in 
every  instance.  If  the  primary  cause  is  eliminated  early  in 
an  acute  simple  adenitis  it  is  unusual  for  suppuration  to  take  place. 


FIG.  63. — LOCATION  OF  THE  PRIN- 
CIPAL LYMPHATIC  GLANDS  OF  THE 
TRUNK. 

(For  explanation  of  the  diagnostic 
significance  of  their  enlargement, 
see  numerals  below.) 

9.  Infections    of    the    neck    and 
occasionally  during  the  course 
of  diphtheria. 

10.  Infections  affecting  the  arm, 
the  axilla,  and  the  upper  por- 
tions   of   the  chest,  anteriorly 
and  posteriorly. 

11.  Infections  of  the  hand,  and 
especially   of   the   three   inner 
fingers.     Quite  frequently  this 
is  enlarged  during  the  course 
of  a  syphilitic  eruption. 

12.  Infections  affecting  the  lower 
limbs,    and     particularly     the 
thighs  and  sometimes  during  the 
course  of  syphilis.     In  rare  in- 
stances  these    glands    are    af- 
fected   in   rubella. 


SIMPLE    CHRONIC    ADENITIS  165 

We  are  convinced  that,  despite  all  that  is  done  to  remove  the 
local  causes  and  give  the  child  relief,  there  still  remains  an  oppor- 
tunity to  still  further  protect  the  patient  by  the  judicious  adminis- 
tration of  such  tonics  as  iron,  arsenic,  and  cod-liver  oil. 

The  best  preparation  of  iron  to  use  is  the  syrup  of  the  iodid,  and 
this  may  be  given  in  three-  to  five-drop  doses  to  an  infant  of  six 
months,  five  to  ten  drops  to  one  of  a  year,  and  ten  to  twenty  drops 
to  the  older  children.  It  is  easily  taken  when  mixed  with  sufficient 
water. 

Fowler's  solution  of  arsenic  is  a  valuable  adjunct  to  the  iron  or 
may  be  used  alone,  but  not  in  infants  under  one  jear  of  age.  One 
drop  may  be  given  to  the  infant  of  a  year  and,  although  there  are 
idiosyncrasies  to  the  drug,  most  children  take  it  well,  and  one  drop 
may  be  given  for  each  year  of  the  child's  age,  up  to  the  fifth  year. 
It  must  always  be  well  diluted. 

In  cod-liver  oil  we  have  one  of  the  very  best  tonics  in  this  con- 
dition. There  is  often  a  nutritional  fault  and  the  child  needs  the 
fats.  In  commencing  the  administration  of  the  oil  the  dose  should 
be  a  very  small  one,  no  matter  what  the  particular  preparation  used, 
and  it  should  be  cautiously  increased  as  the  child  will  tolerate  it. 
A  small  quantity  taken  and  retained  without  any  evidences  of  diges- 
tive disturbance  will  do  more  good  than  a  larger  quantity  borne 
less  comfortably. 

In  regulating  the  dietary  of  the  child  the  fats  should  be  given 
rather  freely. 

SIMPLE   CHRONIC   ADENITIS 

Simple  chronic  adenitis  is  not  nearly  so  common  as  the  simple 
acute  form  and  after  the  fifth  year  of  life  it  is  quite  rare. 

It  consists  of  a  simple  hyperplasia  of  the  lymph  nodes  and  may 
follow  an  acute  adenitis  or  result  from  subacute  or  chronic  inflam- 
mations of  the  various  mucous  membranes  or  of  the  skin. 

It  is  more  common  for  an  acute  adenitis  to  follow  a  chronic 
than  for  the  chronic  to  be  subsequent  to  the  acute,  because  the  acute 
form  is  usually  added  through  the  agency  of  some  infection. 


166  ADENITIS 

Symptoms. — The  symptoms  are  quite  constant.  The  glands  upon 
one  or  both  (commonly  upon  both)  sides  of  the  neck  become  swollen 
and,  as  a  rule,  a  group  of  glands  instead  of  a  solitary  gland  is  in- 
volved. This  swelling  usually  increases  very  slowly  over  a  period 
of  from  one  to  two  months  and  then  remains  stationary  for  about 
a  similar  period,  after  which  there  is  a  very  slow  subsidence  which 
may  persist  over  several  months.  The  degree  of  swelling  is  not 
nearly  so  great  as  in  the  acute  form,  and  constitutional  symptoms 
are  usually  entirely  absent.  There  is  no  tendency  to  either  suppura- 
tion or  caseation  of  the  glands  involved. 

Diagnosis. — The  diagnosis  is  rendered  very  easy  if  the  usual 
course  of  the  disease  is  recalled.  The  chief  difficulty  in  differentia- 
tion comes  from  tuberculous  adenitis. 

The  age  incidence  of  chronic  adenitis  is  much  earlier  than  in 
the  tuberculous  form,  occurring,  as  it  does,  usually  before  the  third 
year  of  life  and  very  rarely  after  the  fifth  year,  while  the  tubercu- 
lous form  is  observed  most  commonly  after  the  fifth  year. 

Neither  is  the  course  of  the  disease  toward  suppuration  and 
caseation,  which  is  not  always  true  of  the  tuberculous  form.  Dur- 
ing the  course  of  tuberculous  adenitis  the  glands  become  adherent 
to  the  skin,  to  each  other,  and  to  the  surrounding  tissues.  They 
enlarge  much  more  slowly  than  in  chronic  adenitis,  but  to  a  greater 
degree,  as  a  rule,  than  in  even  the  simple  acute  form. 

In  the  simple  chronic  variety  there  is  practically  always  an  ob- 
tainable history  of  some  definite  etiological  factor,  which  is  absent 
in  the  tuberculous  form.  The  family  history  is  also  a  very  important 
factor  in  the  latter  variety  of  adenitis.  Constitutional  treatment 
does  not  yield  prompt  or  entirely  satisfactory  results  in  tuberculous 
adenitis. 

Treatment.  — The  treatment  does  not  call  for  surgical  interference 
in  the  simple  cases,  but  in  those  which  are  persistent  or  which  have 
about  them  such  features  and  history  as  make  it  practically  impos- 
sible to  make  a  positive  diagnosis  from  the  tuberculous  form  opera- 
tion may  be  advisable,  as  giving  the  child  the  benefit  of  the  doubt. 
However,  before  surgical  intervention  there  should  be  instituted  a 
persistent  trial,  over  a  period  of  at  least  a  month,  of  such  measures 


SYPHILITIC    ADENITIS  1(57 

as  are  known  to  influence  and  benefit  a  simple  chronic  adenitis,  so 
that  the  adequately  tried  therapeutic  test  may  substantiate  the  diag- 
nostic tests. 

Local  applications  are  of  very  doubtful  value  and,  for  the  same 
reasons  as  were  mentioned  in  the  discussion  of  simple  acute  adenitis 
(see  page  163),  they  may  prove  harmful. 

The  greatest  amount  of  benefit  will  be  obtained  by  such  measures 
as  insure  the  highest  nutritional  efficiency  for  the  child  and  having 
this  augmented  by  the  administration  of  suitable  tonics.  The  best 
of  these  are  iron,  arsenic,  and  cod-liver  oil.  To  avoid  repetition 
the  reader  is  referred  to  the  preceding  section  (page  105)  for  the 
details  of  their  administration. 

Surgery  should  be  added  to  this  treatment  to  the  extent  that  it 
can  relieve  the  child  by  the  removal  of  any  of  the  various  local 
causes  that  are  most  commonly  found  in  the  nose  or  the  nasopharynx 
and  the  mouth. 

Change  of  climate  may  be  necessary  in  some  instances  until  the 
child  can  be  brought  to  a  state  of  physical  efficiency  which  will 
withstand  the  strain  of  its  usual  surroundings.  In  every  instance 
out-of-door  life  must  be  insisted  upon  with  a  moderate  amount  of 
exercise. 

SYPHILITIC   ADENITIS 

It  is  only  rarely  that  the  infant  suffering  from  a  congenital 
syphilis  shows  any  considerable  degree  of  glandular  enlargement 
as  a  direct  result  of  the  disease.  As  all  infants  are  liable  to  simple 
acute  adenitis,  and  especially  those  who  are  rendered  less  resistant 
by  intercurrent  disease  or  nutritional  fault,  it  is  common  to  find 
the  syphilitic  infant  the  subject  of  a  simple  acute  adenitis,  but  this 
must  not  be  mistaken  for  a  syphilitic  adenitis.  As  a  late  manifesta- 
tion of  syphilis,  glandular  enlargements  frequently  occur,  however. 
Their  recognition  is  rendered  easy  by  the  fact  of  their  late  appear- 
ance, because,  long  before  such  an  event  occurs,  the  diagnosis  of 
syphilis  has  been  positively  made.  The  affected  glands  are  very  hard 
and  insensitive  and  also  freely  movable.  The  effect  of  treatment 


168 


FIG.  64. — TUBERCULOUS  ADENITIS 


FIG.  65. — TUBERCULOUS  ADENITIS  SHOW- 
ING THE  MARKED  ENLARGEMENT  WHICH 
MAY  SOMETIMES  TAKE  PLACE  WITHOUT 
THE  GLANDS  BREAKING  DOWN. 

The  redness  on  the  edges  of  these  swellings 
was  not  due  to  caseation  but  was  the 
direct  result  of  irritation  from  a  stiff 
collar. 


rapidly  removes  any 
doubt  as  to  the  underly- 
ing cause.  In  their  local 
appearance  they  very 
much  resemble  tubercu- 
lous glands. 

The  diagnosis  of 
syphilis  is  considered 
fully  on  page  150. 


TUBERCULOUS 
ADENITIS 


Tuberculous  adenitis  pre- 
sents some  rather  striking  fea- 
tures; as,  for  instance,  its 
rarity  during  infancy,  its  com- 
mon occurrence  in  later  child- 
hood, and  its  common  occur- 
rence as  the  only  tuberculous  le- 
sion iri  the  body  in  many  in- 
stances. 

Etiology.  — The  usual  occur- 
rence is  between  the  ages  of 
four  to  ten  years,  and  the  cer- 
vical glands  are  those  which  are 
most  often  affected.  The  con- 
dition is  rather  favored  by  the 
occurrence  of  the  other  forms 
of  adenitis,  because  by  their  in- 
fluence the  vitality  of  the  gland 
is  considerably  lowered  and  the 
part  rendered  more  liable  to  the 
successful  invasion  of  the  tu- 
bercle bacillus.  Local  condi- 


TUBEKCULOUS    ADENITIS 


169 


tions  which  favor  infection,  such  as  adenoids,  enlarged  tonsils, 
chronic  pharyngitis,  otitis,  facial  eczema,  stomatitis,  caries  of  the 
teeth,  etc.,  .are  prolific  causes. 

Children  who  are  susceptible  to  glandular  enlargements  and 
those  with  a  decided  tuberculous  family  history  are  the  ones  most 
often  affected.  We  might  say,  then,  that  tuberculous  adenitis  is 
due  to  a  primary  infection  in  those  who  are  especially  susceptible 
to  tuberculous  dis- 
ease; to  a  secondary 
infection  of  an  al- 
ready  devitalized 
part,  or  to  both. 

Lesions.  —  The 
process  is  essentially 
a  chronic  one,  al- 
though there  are  two 
more  or  less  distinct 
classes  of  cases ;  one 
in  which  the  process 
is  rapid  with  early 
caseation  or  sup- 
puration ;  -the  other 
much  more  chronic 
and  with  much-de- 
layed or  absent  case- 
ation and  softening. 
The  first  effect  of 

the  tuberculous  infection  is  hyperemia  and  swelling,  the  glands  be- 
ing pale  pink  in  color  and  homogeneous.  Next  there  occurs  a  pro- 
liferation of  the  adenoid  reticulum,  the  glands  becoming  more  firm 
and  finally  softening  with  destruction  or  conversion  of  lymphoid 
cells  and  caseation.  Softening  usually  starts  in  the  center  of  the 

gland. 

The  inflammation  in  the  gland  is  not  confined  to  that  part,  but 
involves  the  surrounding  tissues  also,  so  that  adhesions  are  quickly 
formed. 


Fio.  66. — ABSCESS  POINTING  IN  FRONT  OF  UPPER   PART 
OF  THE  STERNOMASTOID.     (Dowd.) 


170 


ADEXITTS 


When  an  abscess  forms  the  content  of  the  cavity  is  largely  de- 
rived from  the  tissue  of  the  broken  down  node,  and  therefore  there 
is  very  little  pus  but  a  mass  of  curdy  material.  This  material  often 
does  not  show  the  presence  of  tubercle  bacilli,  for  they  are  numerous 
only  in  the  early  stages  of  gland  involvement.  Several  glands  may 
fuse  together  and  the  adhesions  become  attached  to  all  surrounding 
tissue,  whether  it  be  blood  vessel,  fascia,  nerve,  skin,  or  muscle.  We 
must  not  be  unmindful,  however,  that  considerable  pus  may  be 
evacuated  from  a  tuberculous  abscess,  because  there  has  been  added 

a  mixed  infection. 

It  is  unusual  not 
to  find  several  glands 
or  a  chain  of  them 
affected.  The  course 
of  the  local  condition 
will  depend  upon  the 
virulence  of  the  in- 
fection and  the  re- 
sisting powers  of  the 
child ;  therefore  we 
may  see  either  reso- 
lution, encapsulation, 
calcification,  or  sup- 
puration. Thus  ab- 
sorption may  occur 
before  caseation ; 
caseation  may  be  fol- 
lowed by  encapsula- 
tion and  contraction ;  calcification  may  occur,  but  is  rare,  or  lique- 
faction may  result  in  the  external  abscess. 

Symptoms. — The  glandular  swellings  are  the  only  evidences  of  the 
disease  at  first.  This  swelling  comes  on  gradually  and  usually  in- 
volves both  sides,  and  it  is  only  later  in  the  course  that  one  side 
seems  to  progress  more  rapidly  than  the  other. 

One  feature  of  the  enlargement  is  that  it  is  inconsistent ;  at  one 
time  advancing  rapidly,  then  subsiding  somewhat  or  being  arrested 


FIG.  67. — ABSCESS  POINTING  IN  FRONT  OF  LOWER  PART 
OF  STERNOMASTOID.     (Dowd.) 


TUBERCULOUS    ADENITIS 


171 


for  a  time.  At  times  it  seems  as  though  it  required  some  active  local 
condition  to  start  it  up  again,  such  as  an  infectious  disease,  a  stomati- 
tis, or  a  lowering  of  the  child's  general  health,  and  during  these  acute 
exacerbations  the  parts  may  become  quite  painful  with  the  ordinary 
signs  of  acute  inflammation.  The  chronicity  of  the  process  is 
marked,  so  that  several  years  may  elapse  before  suppuration  actuallv 
takes  place. 

The  most  common  site  of  first  appearance  is  just  in  front  of 
the  sternocleidomastoid  muscle.  In  the  rapidly  developing  cases  the 
glands  are  of  a  con- 
siderable size  within 
two  months,  although 
much  longer  periods 
are  the  rule.  The 
outline  of  the  gland 
can  be  readily  made 
out  at  first,  and  they 
are  freely  movable, 
but  later  they  become 
adherent,  and  this 
tendency  to  adhesion 
persistently  contin- 
ues, even  the  individ- 
ual glands  becoming 
like  one  firm  mass. 
The  skin  becomes 
discolored  as  the 
process  becomes  more 
superficial,  and  areas 
of  softening  may  be 

detected  with  fluctuation  until  the  skin  gives  way  and  there  occurs 
the  discharge  of  thick,  curdy  material  with  little  pus. 

This  may  continue  until  the  whole  mass  is  discharged,  and  even 
be  repeated  as  other  tissues  break  down.  This  spontaneous  rupture 
usually  results  in  large,  intractable  ulcers,  the  skin  having  been  de- 
vitalized over  a  considerable  area  and  having  an  unhealthy  appear- 


FIG.  68. — ABSCESS   POINTING   BEHIND   UPPER   PART 
STERNOMASTOID.     (Dowd.) 


172 


ADENITIS 


ance.  They  may  resist  all  treatment  and  the  subsequent  scars  are 
large,  if  not  actually  deforming.  They  are  more  or  less  tender  and 
adherent  to  the  deep  tissues. 

The  general  health  of  the  affected  child  may  remain  reasonably 
good,  much  more  so  than  we  would  expect  with  such  a  process  active 
in  the  glands. 

Diagnosis. — The  diagnosis  is  not  difficult  when  we  recall  the  dis- 
tinguishing features, 
which  are :  the  age 
of  the  child  (four  to 
ten  years),  the  tri- 
fling or  apparently 
absent  primary 
cause,  the  irregular 
course  of  the  swell- 
ings, the  chronicity 
of  the  disease,  the 
tuberculous  family 
history,  and  the 
marked  tendency  to- 
ward caseation,  sof- 
tening, and  abscess. 
Simple  acute  ad- 
enitis occurs  in  in- 
fancy m  o  s  1 1  y,  is 
much  more  rapid  in 
its  course,  and-  has  a 
short  course.  Simple 

adenitis,  whether  acute  or  chronic,  can  be  traced  to  some  very  definite 
cause,  and  the  course  is  not  toward  caseation  or  suppuration  when 
uncomplicated.  Constitutional  treatment  gives  quick  results  in  the 
simple  forms,  while  it  is  not  efficient  in  the  tuberculous.  If  sup- 
puration takes  place  in  the  simple  forms  it  is  early  (usually  within 
the  first  four  to  five  weeks). 

The  effects  of  treatment  would  at  once  differentiate  syphilitic 
adenitis.  Hodgkin's  disease  and  malignant  disease  could  offer  no 


FIG.  69. — ABSCESS    POINTING    IN    FRONT 
MASTOID.     (Dowd.) 


OF     STEKNO- 


TUBERCULOUS    ADENITIS 


173 


difficulty,  as  the 
course  of  each  is  so 
entirely  different. 

Prognosis.  —  Fi- 
nal recovery  can  be 
predicted  even 
though  the  course  is 
very  chronic,  for, 
in  itself,  tuberculous 
adenitis  is  not  de- 
structive to  life.  But 
the  danger  is  always 
present  of  mixed  in- 
fection, and  the  child 
is  never  entirely  safe 
with  that  possibility 
in  view.  The  possi- 
bility of  a  general 
infection  must  also 
be  borne  in  mind. 

Treatment.  —  The 
general  treatment  de- 
mands that  the 
child's  surroundings 
be  changed  sufficient- 
ly to  give  it  the  best 
possible  chance  to 
build  up.  It  is  most 
important  that  any 
nutritional  fault  be 
corrected  at  once. 
Here,  again,  as  in 
the  simple  forms  of 
the  disease,  iron,  ar- 
senic, and  cod-liver 
oil  are  of  great  bene- 
fit (see  page  165). 


FIG.  70. — SHOWING  THAT  IT  is  UNSAFE  TO  EXPECT  THE 
DISEASE  TO  BE  SELF-LIMITED,  EVEN  WHEN  THE 
CHILD  is  AT  THE  MOST  FAVORABLE  AGE.  (Dowd.) 


FIG.  71. — ILLUSTRATIVE  OF  THE  SAME  PROPOSITION  AS 
FIGURE  70.     (Dowd.) 


174  OSTEOMYELITIS 

Local  treatment  of  the  affected  parts  is  not  only  useless,  but 
is  positively  harmful,  in  that  the  glands  are  subjected  to  unnecessary 
injury. 

It  is  very  important,  however,  to  remove  all  possible  sources  of 
irritation,  such  as  hypertrophied  tonsils,  adenoids,  pathological  con- 
ditions in  the  nose,  chronic  otitis,  conjunctivitis,  caries,  ulcerations 
about  the  nose  and  mouth,  etc. 

Operative  measures  are  indicated  if  the  above  means  have  been 
tried  for  two  or  perhaps  three  months  without  success,  as  is  shown 
by  the  glands  continuing  to  increase  in  size  or  in  number,  and  par- 
ticularly if  softening  occurs. 

Under  the  above  conditions  it  is  unwise  to  leave  the  cure  to 
Mature,  because  there  always  remains  the  danger  of  a  general  in- 
fection or  an  added  one  of  a  different  type  and  the  scarring  and 
chronicity  of  the  non-operative  cure  are  a  disadvantage  and  always 
remain  an  uncertainty.  And  when  the  operative  procedure  is 
decided  upon  it  must  be  radical  enough  so  that  all  of  the  diseased 
tissues  are  removed  through  a  free  incision. 


OSTEOMYELITIS 

In  considering  the  surgical  diseases  of  bone,  the  fact  should  be 
recalled  that  bone  is  not  merely  the  framework  on  which  the  tissues 
are  arranged,  but  that  it  is  itself  a  tissue — a  tissue,  though  dense, 
well  supplied  with  blood  conveyed  by  periosteal  and  medullary  ves- 
sels. Thus,  when  bone  is  divided  or  injured,  it  bleeds  like  other 
tissue,  and  hence  shows  the  same  inflammatory  reactions  to  irrita- 
tion. Furthermore,  the  ends  of  the  long  bones  (epiphyses)  are  at- 
tached to  the  shaft  (diaphysis)  by  means  of  its  epipliyseal  cartilage, 
from  which  the  bone  continues  to  grow  in  length  until  it  has  reached 
maturity,  when  the  cartilaginous  junction  disappears  and  the  epi- 
physis  is  solidly  joined  to  the  shaft.  Hence  bones  increase  in  length 
by  continued  ossification  in  the  epiphyseal  cartilage.  Bones  increase 


INFECTIVE    OSTEOMYELITIS  175 

in  circumference  by  the  deposition  of  new  bone  from  the  deeper 
layer  of  the  periosteum. 

Anything  which  interferes  with  growth  at  the  epiphyseal  line 
will  lead  to  diminution  in  the  length  which  the  adult  bone  should 
attain.  Anything  which  interferes  with  growth  from  the  deeper 
layer  of  periosteum  will  result  in  a  disproportionate  thickness  of 
bone. 

Again,  the  marrow  inside  the  shaft  of  the  long  bones  is  important ; 
for  we  note  that  in  children  and  up  to  the  age  of  fifteen  this  mar- 
row is  red,  extremely  vascular,  and  that  it  forms  one  of  the  blood 
factories  of  the  body.  With  adult  life  the  marrow  becomes  yellow, 
owing  to  the  deposition  of  fat  cells,  and  its  blood-forming  function 
ceases. 

INFECTIVE    OSTEOMYELITIS 

Infective  osteomyelitis  is  an  acute  suppuration  of  the  bone  due 
to  the  lodgment  and  growth  in  the  b6ne  marrow  of  pyogenic  organ- 
isms. This  suppurative  process  assumes  distinct  characteristics 
'because  of  the  anatomical  peculiarities  of  the  tissue  involved.  Its 
virulence  and  extensive  ravages  are  evident  when  we  consider  the 
kind  of  tissue  affected,  and  the  dense  bony  walls  which  imprison  the 
products  of  inflammation.  It  is  preeminently  a  disease  of  childhood 
and  adolescence,  and,  while  it  prefers  the  diaphysis  of  the  long  bones 
near  the  fertile  epiphyses,  no  bone  of  the  body  is  exempt. 

Etiology  and  Pathology. — PREDISPOSING  CAUSES. — It  is  evident 
that  osteomyelitic  infection  is  favored  by  suitable  soil.  Thus  we 
note  its  preference  for  growing  bones — one-half  the  cases  appear  be- 
tween the  ages  of  thirteen  and  seventeen.  Again,  an  injury  or  blow 
which  lowers  the  vital  resistance  of  the  tissue  often  precedes  the 
appearance  of  the  disease — thus,  for  example,  the  disease  occurs 
three  times  as  frequently  in  boys  as  in  girls,  which  emphasizes  the 
influence  of  trauma,  to  which  boys  are  more  exposed.  Faulty  nutri- 
tion, exposure  to  cold,  and  extreme  fatigue  must  also  be  reckoned 
as  factors  in  preparing  the  soil,  while  previous  infectious  diseases 
(the  exanthemata,  typhoid,  pneumonia)  often  provide  the  invading 
microorganisms. 


176  OSTEOMYELITIS 

The  DIRECT  CAUSE  is  a  pyogenic  infection  from  a  near-by  wound 
(compound  fracture,  etc.),  or,  in  the  great  majority  of  cases,  carried 
by  way  of  the  blood  vessels  (hematogenous). 

The  infecting  mechanism  is  most  commonly  the  Staphylococcus 
pyogenes  aureus,  more  rarely  the  albus  and  citreus.  In  a  few  cases 
it  is  the  streptococcus.  In  some  cases  the  pneumococcus.  In  chil- 
dren under  two  years  we  may  get  a  pneumococcus  osteomyelitis  with- 
out an  antecedent  pneumonia.  The  bacteria  are  deposited  by  the 
blood  vessels  in  the  bone  marrow,  which,  because  of  its  own  dimin- 
ished power  of  resistance  or  the  great  virulence  of  the  germ,  finally 
perishes  in  the  struggle  and  there  is  inaugurated  a  suppurative 
inflammation  which  rapidly  spreads  through  the  Haversian  canals, 
reaches  the  periosteum,  leads  to  suppurative  periostitis,  lifts  the 
periosteum  from  the  bone,  denudes  the  bone  of  its  nutrient  membrane, 
and  leaves  a  necrotic  mass  of  bone  involving  either  a  part  or  the 
entire  shaft. 

The  rarer  cases  are  those  caused  by  inflammation  through  the 
periosteum.  As  the  process  proceeds  the  necrotic  area  is  gradually 
separated  from  the  healthy  bone  by  a  layer  of  granulation  tissue, 
the  periosteum  forms  new  masses  of  bone  which  walls  off  and  en- 
capsulates the  sequestra,  through  this  wall  are  found  openings  for 
the  drainage  of  pus,  which  makes  its  way  through  the  overlying  soft 
parts  and  leads  to  fistula  formation. 

The  granulation  tissue  surrounding  the  sequestra  has  a  digestive 
action  which,  in  the  course  of  years,  is  capable  of  dissolving  large 
sequestra  and  thus  bringing  about  a  spontaneous  cure,  providing  the 
gravity  of  the  disease  and  the  long-continued  suppuration  do  not 
lead  to  a  fatal  termination.  Remember  that  it  is  impossible  to 
judge  of  the  extent  of  an  osseous  inflammation  by  its  intensity  and 
the  extent  of  the  periosteal  lesion. 

Sometimes  a  limited  osteomyelitis  is  associated  with  considerable 
periosteal  detachment,  and  again  the  periosteum  is  often  little  af- 
fected, while  the  bone  may  be  infiltrated  from  its  surface  to  the  depth 
of  its  medullary  canal. 

The  favorite  place  for  the  disease  is  the  long  bones,  and  the  parts 
most  frequently  affected  are  in  the  order  named :  the  lower  extremity 


INFECTIVE    OSTEOMYELITIS 


177 


of  the  femur,  the  upper  end  of  the  tibia  and  fibula,  the  upper  end 
of  the  humerus,  the  inferior  extremity  of  the  radius  and  ulna. 

Symptoms, — A  previously  healthy  child  is 
suddenly  attacked  with  intense  pain  localized 
near  the  ends  of  one  of  the  long  bones  accom- 
panied by  chills  and  high  fever.  The  pain  of 
osteomyelitis  has  two  characteristics: 

(a)  Its  sudden  onset.     As  Estor  suggests, 
ask  the  patient  with  osteomyelitis  to  tell  you 
what  day  the  disease  appeared  and  his  response 
will  be  precise,  not  only  as  to  the  day,  but  the 
hour  of  the  first  chill. 

(b)  Its  intensity.     The  excruciating  sever- 
ity of  the  pain,  aggravated  by  the  slightest  mo- 
tion or  pressure,  is  comparable  to  no  other  pain 
symptom.      It  may  be   referred  to   the   entire 
bone  or  to  a  neighboring  joint. 

One  of  the  most  characteristic  symptoms  is 
loss  of  function  in  the  affected  limb.  The  pa- 
tient is  absolutely  unable  to  move  the  limb  in 
the  slightest  manner. 

There  is  tenderness,  sometimes  involving 
the  entire  bone,  but  the  greatest  tenderness  is 
over  the  inflammatory  focus.  It  is  obvious  that, 
since  the  products  of  suppuration  are  confined 
within  an  impermeable  bony  wall,  the  amount 
of  septic  absorption  and  the  symptoms  of  tox- 
emia are  extreme.  Hence  the  pulse  is  rapid,  THE  TIBIA.  (Lexer.) 

,  ,  .    ,        .  j.i  a-  Purulent     forces     in 

the  temperature  high,  the  tongue  dry,  the  eyes          metaphysis    which 

sunken.     Delirium,  stupor,  and  coma  succeed 

each   other   so   rapidly   that   the   characteristic 

local  symptoms   often   entirely   escape   notice. 

The  leukocyte  count  is  high — 25,000  to  30,000, 

with  a  relative  increase  of  the  polymorphonu- 

clear  leukocytes. 

Locally  there  is  swelling  of  the  soft  parts  over  the  infected  bone. 


[G" 


epiphysis;  b.  Peri- 
osteum raised  by 
pus;  c.  Phlegmon 
of  the  medulla;  d. 
Separation  of  the 
epiphysis ;  e.  Rup- 
ture into  joint. 


178  OSTEOMYELITIS 

The  skin  becomes  red  and  edematous,  and  the  neighboring  lymph 
glands  are  swollen  and  painful.  Fluctuation  of  the  soft  parts  indi- 
cates abscess,  which  may  open  spontaneously  and  be  followed  by 
fistula  formation.  Escape  of  the  pus  externally  is  followed  by  cessa- 
tion of  pain  and  fever.  Nor  is  the  process  always  confined  to  the 
bone  first  attacked.  It  may  extend  to  the  epiphysis,  lead  to  its  de- 
tachment and  final  destruction,  enter  the  joint  and  cause  a  suppura- 
tive  arthritis  (see  Fig.  72). 

Likewise  the  infection  may  be  carried  by  the  circulation  to  other 
bones  and  there  may  result  multiple  suppurative  foci.  All  these 
complications  add  to  the  gravity  of  the  situation  and  may  lead  to 
death. 

Diagnosis. — With  a  disease  presenting  such  striking  characteris- 
tics it  may  be  difficult  to  explain  why  so  many  cases  of  acute  osteo- 
myelitis are  compromised  by  a  procrastinating  medical  treatment 
when  the  indications  for  surgical  intervention  are  immediate.  As  a 
matter  of  experience  osteomyelitis  is  often  confounded  with  typhoid 
fever,  acute  articular  rheumatism,  and  meningitis.  This  is  true 
especially  of  rheumatism. 

The  explanation  is  not  difficult  when  we  consider  that  when  the 
doctor  first  sees  the  case  it  is  usually  after  the  severe  initial  symptoms. 
The  clinical  picture  has  changed  to  one  of  profound  prostration  with 
cerebral  symptoms.  In  other  words,  the  delirium,  stupor.,  and  coma 
have  succeeded  one  another  in  such  rapid  succession  that  the  severe 
initial  and  localizing  symptoms  are  masked  by  the  profound  septic 
intoxication.  The  picture  is  now  one  of  septic  fever  not  unlike 
typhoid,  and,  if  a  careful  history  of  the  onset  is  not  obtained  and 
a  careful  examination,  especially  of  the  long  bones,  is  neglected, 
confusion  is  inevitable. 

Rule:  Every  child  suddenly  attacked  with  high  fever  and  de- 
lirium, of  the  origin  of  which  there  is  the  slightest  doubt,  should  be 
carefully  examined  for  osteomyelitic  foci. 

Typhoid  Differential. — The  leukocyte  count  is  characteristic. 
In  osteomyelitis  the  leukocytosis  is  marked ;  in  typhoid  it  is  absent. 
Compare  the  onset  of  'the  two  diseases,  the  difference  is  clearly  de- 
fined; typhoid  is  not  sudden,  it  is  preceded  by  well-known  prodro- 


INFECTIVE    OSTEOMYELITIS  179 

mata,  with  diarrhea  and  abdominal  tenderness.  None  of  these  are 
present  in  osteomyelitis,  besides  typhoid  presents  no  acute  bone 
symptoms.  Widal  reaction  is  of  little  use  as  an  early  means  of 
diagnosis;  its  value  as  a  diagnostic  aid  is  in  the  second  week  of 
typhoid. 

In  painful  bone  and  joint  affections  rheumatism  is  the  last  thing 
to  think  of. 

Acute  Articular  Rheumatism  Differential. — Rheumatism  affects 
more  than  one  joint  and  the  pain  is  circumscribed,  not  the  diffused 
and  reflected  pain  of  osteomyelitis.  The  maximum  of  pain  is  inter- 
articular,  not  epiphyseal  or  diaphyseal.  Joint  symptoms  in  osteomy- 
elitis are  late  symptoms.  The  general  symptoms  in  rheumatism  are 
much  less  severe  than  in  osteomyelitis. 

In  all  cases  of  doubt  the  X-ray  is  an  important  aid  in  clarifying 
the  diagnosis. 

Prognosis  is  grave,  not  only  in  the  acute  forms,  which  often  have 
a  fatal  termination,  but  in  those  less  severe  forms  where  the  disease 
becomes  chronic  and  there  is  established  a  constant  evolution  of  new 
sequestra,  new  abscesses,  new  fistulae,  extending  over  a  number  of 
years  and  bringing  about  chronic  visceral  lesions,  amyloid  degenera- 
tion of  the  liver  and  kidneys. 

Treatment. — There  is  only  one  treatment  for  osteomyelitis:  radi- 
cal surgical  intervention  without  delay,  since  there  is  no  contraindi- 
cation to  operation  when  once  the  diagnosis  of  acute  osteomyelitis 
has  been  made.  Furthermore,  superficial  incisions  down  to  the 
soft  parts  are  futile.  The  surgical  relief  of  osteomyelitis  contem- 
plates nothing  less  than  an  opening  in  the  bone  down  to  the  marrow — 
the  focus  of  infection.  Remember  that  the  pus  is  in  the  medullary 
canal  as  well  as  under  the  periosteum.  Hence,  periosteal  incisions 
are  insufficient. 

Method. — Make  a  free  incision  the  full  length  of  the  affected 
part  down  to  the  bone,  being  careful  to  avoid  the  tendons,  vessels, 
and  nerves,  and  to  secure  perfect  hemostasis.  Be  sure  to  lay  the 
periosteum  open  the  full  extent  of  the  pathological  process;  then 
open  up  the  bone  either  by  trephine  at  three  or  four  points,  or  by 
chiseling  a  groove  out  of  the  bone  as  far  as  the  pus  infiltration  of 


180  OSTEOMYELITIS 

the  marrow  extends.    Be  careful  not  to  lift  up  or  injure  the  perios- 
teum unnecessarily. 

The  pus  is  to  be  carefully  wiped  out  and  the  bone  cavity  drained. 
A  specimen  of  the  pus  should  be  examined  to  discover  the  infecting 
organism  and  the  appropriate  vaccine  prepared  for  injection.  Curet- 
ting, irrigating  with  antiseptic  solutions,  and  otherwise  disturbing 
the  infected  marrow  are  to  be  avoided.  For  it  will  be  recalled  that 
the  internal  surface  is  lined  with  endosteum — the  bone-forming 
membrane  of  the  internal  surface  of  the  cortex.  Curetting  only 
destroys  the  integrity  of  the  endosteum  and  leads  to  necrosis  of  the 
inside  of  the  cortex. 

The  treatment  of  osteomyelitis  is  compromised  as  much  by  super- 
ficial incisions  as  by  late  incisions.  Trephining  the  bone  adds  noth- 
ing to  the  risk  of  operation — it  may  not  only  save  the  bone,  it  may 
save  life. 

Interfere  as  little  as  possible  with  the  epiphyseal  line,  especially 
at  the  knee.  In  the  lower  extremity  the  increase  in  length  of  the 
bones  is  greatest  at  the  knee.  In  the  upper  extremity  the  increase  is 
greatest  at  the  shoulder  and  wrist. 

In  cases  operated  upon  very  early  (which  is  exceptional)  before 
the  endosteum  is  destroyed,  there  will  be  no  formation  of  a  seques- 
trum, and  the  wound  will  heal  by  granulation.  In  the  majority  of 
cases  (late  operation,  spontaneous  opening,  inadequate  drainage, 
etc.)  the  endosteum  has  been  destroyed,  a  portion  of  the  bone  ne- 
croses, there  remains  a  sequestrum,  and  the  disease  passes  into  the 
subacute  or  chronic  stage,  in  which  is  seen  the  process  of  sequestra- 
tion by  which  the  necrotic  bone  separates  and  forms  a  sequestrum — 
a  foreign  body — surrounded  by  a  shell  of  new  bony  formation,  which 
is  perforated  by  fistulae  and  continues  to  discharge  pus  so  long  as  the 
sequestrum  remains. 

It  is  evident  that  the  sequestrum  must  be  removed,  either  spon- 
taneously or  by  operation,  and  the  management  of  this  stage  of  the 
disease  demands  surgical  discrimination.  Formerly  it  was  thought 
wise  to  wait  until  the  sequestrum  was  freely  movable  and  surrounded 
by  a  dense  shell  of  bone.  No  one  rule  of  procedure  is  broad  enough 
to  cover  all  cases  and  the  surgeon  must  discreetly  select  the  operation 


INFECTIVE    OSTEOMYELITIS 


181 


which  best  fulfills  the   anatomical   and  pathological   requirements. 
Nichols  has  ably  classified  these  cases  and  their  treatment  as  follows : 

(1)  Removal  of  the  necrotic  sequestrum  before  the  hard  bony 
shell  is  formed,  and  while  the  periosteum  is  still  plas- 
tic. This  operation  is  applicable  where  "an  accessory 
bone  is  present  which  may  act  as  a  splint  and  main- 
tain the  length  of  the  limb  during  the  process  of  bone 
regeneration."  For  example,  the  fibula  may  act  as  a 
splint  while  the  tibia  is  undergoing  regeneration. 
Again,  it  is  indicated  "in  those  cases  in  which  there 
has  been  an  extensive  destruction  of  the  entire  diam- 
eter of  the  diaphysis  over  a  greater  or  lesser  length." 

The  usual  time  for  this  operation  is  at  the  end  of 
the  eighth  week. 

The  operation  contemplates  the  removal  of  the  dis- 
eased portion  of  the  shaft  subperiosteally,  the  excision 
being  made  through  healthy  bone.  The  periosteum 
is  carefully  stripped  off  and  preserved  in  its  integrity 
so  that  it  forms  a  bridge  between  the  two  remaining 

O  o 

ends  of  bone  over  which  a  new  shaft  of  bone  is  formed 
(Fig.  73). 

The  results  in  properly  selected  cases  are  excel- 
lent. The  newly  regenerated  bone  is  functionally  sat- 
isfactory and  may  be  used  with  safety  in  from  six  to 


eight  months. 


FIG.  73  — DIA- 
GRAM TO  SHOW 
REMOVAL  OF  A 
PORTION  OF 
THE  TIBIA,  AND 
RELATION 
OF  INFOLDED 
PERIOSTEUM 
WHICH  FORMS 
A  BRIDGE  BE- 
TWEEN THE 
Two  REMAIN- 
ING ENDS  OF 
BONE.  (After 
Nichols -Keen's 
Surgery.) 


(2)  Removal  of  the  necrotic  sequestrum  as  soon 
as  the  involucrum  is  sufficiently  strong  to  guarantee 
the  integrity  of  the  shaft. 

This  procedure  is  indicated  where  there  is  no  ac- 
cessory bone  to  act  as  a  splint,  such  as  the  humerus, 
where  it  is  evident  that  a  removal  of  any  portion  of 
the  shaft  before  a  periosteal  shell  is  formed  must  result  in  deform- 
ing muscular  contractures. 

Furthermore,  the  operation  must  be  done  before  the  involucrum 
becomes  too  dense  and  while  it  still  has  reparative  power  to  fill  up 
the  central  defect  left  by  removal  of  the  sequestrum. 


182  OSTEOMYELITIS 

It  is  often  a  difficult  question  to  decide  when  the  conditions 
are  ripe  for  this  operation.  Nichols  believes  that  the  operation  can 
be  undertaken  when  the  total  diameter  of  the  involucrum  is  equal  to 
one-half  of  the  diameter  of  the  normal  shaft,  and  that  the  time  is 
approximately  twelve  weeks  after  the  acute  infection. 

(3)  Removal  of  sequestrum  with  dense  involucrum.  The  diffi- 
culty with  these  cases  is  not  in  the  removal  of  the  sequestrum,  but 
after  the  sequestrum  is  removed  there  is  still  a  discharging  bony 
cavity  which  refuses  to  heal,  the  inner  surface  of  the  dense  bony  shell 
has  lost  its  power  of  regeneration,  and  there  remains  a  suppurating 
cavity  with  all  its  secondary  dangers. 

The  problem,  then,  is  how  to  obliterate  the  defect  after  the  se- 
questrum is  removed.  The  number  of  procedures  suggested  is  an 
evidence  of  the  difficulties  which  present. 

Prominent  among  these  suggestions  are: 

Filling  the  cavity  with  pieces  of  sponge; 

Utilizing  a  blood  clot,  hoping  for  its  subsequent  organization; 

Filling  the  cavity  with  Mosetig's  iodoform  plug,  which  consists 
of  iodoform  sixty  parts,  spermaceti  forty  parts,  and  oil  of  Sesame 
forty  parts.  This  mixture  remains  solid  at  body  temperature ;  when 
used  it  is  heated  until  it  is  fluid,  poured  into  the  bone  cavity,  where  it 
is  expected  to  form  a  framework  for  bone  deposition. 

It  must  be  evident  that  the  filling  of  bone  cavities  either  with 
blood  clot  or  foreign  substances  is,  as  a  rule,  a  disappointing  pro- 
cedure, since  success  depends  upon  asepsis — a  condition  which,  in 
these  bone  cavities,  it  is  well-nigh  impossible  to  obtain. 

A  far  better  procedure  is  to  remove  the  dense  cortical  shell  ex- 
tensively until  the  bone  surface  is  flattened  and  then  fasten  to  the 
bone  surface  inverted  flaps  of  skin  taken  from  either  side  of  the 
cavity.  In  many  cases  these  skin  flaps  will  adhere  to  the  bone  and 
obliterate  the  cavity. 

Living  Bone  Grafts. — A  few  successes  have  been  reported  by 
this  ingenious  method;  even  entire  joints  have  been  transplanted. 
The  whole  question  of  transplanting  the  living  tissue  of  animals  to 
supply  human  defects  is  in  the  experimental  stage  and  its  employ- 
ment is  suggested,  not  advised. 


RAEER    FORMS    OF    OSTEOMYELITIS  183 

RARER   FORMS    OF    OSTEOMYELITIS 

Periostitis  Albuminosa. — Periostitis  albuminosa,  first  identified  by 
Oilier,  is  really  a  superficial  osteomyelitis,  due  to  an  attenuated  form 
of  one  of  the  pyogenic  organisms,  in  which  the  exudate  is  serous  in- 
stead of  purulent. 

It  is  characterized  by  an  accumulation  of  mucoid  or  gelatinous 
fluid  like  synovia,  situated  between  the  bone  and  the  periosteum. 

It  is  found  especially  in  the  young  and  near  the  epiphyses  of  the 
long  bones. 

The  bone  is  very  slightly  affected,  though  in  some  cases  there 
is  a  superficial  necrosis. 

It  usually  begins  with  sharp  pain  in  the  bone  with  rise  of  tem- 
perature and  considerable  localized  swelling,  which  fluctuates  on 
palpation.  On  incising  the  swelling  we  find  the  periosteum  thick- 
ened and  an  albuminous  fluid  between  the  periosteum  and  bone. 

The  prognosis  is  favorable  and  simple  evacuation  of  the  fluid  is 
sufficient  to  bring  about  a  cure. 

Primary  Chronic  Osteomyelitis. — Primary  chronic  osteomyelitis  is 
that  form  of  osteomyelitis  in  which  the  patient  presents  sequestra  and 
an  hyperostoses  without  any  of  the  previous  characteristic  phenomena 
of  acute  osteomyelitis.  It  is  to  this  form  of  osteomyelitis  that  Paget 
gave  the  name  of  "quiet  necrosis."  The  patient  presents  the  symp- 
toms of  pain  and  swelling  of  the  bone,  but  the  general  state  is  not 
affected — the  bony  changes  take  place  without  suppuration.  This 
silent  change  may  go  on  for  months  or  years  and  finally  become  an 
acute  process. 

To  differentiate  it  from  syphilitic  osteomyelitis  and  osteosarcoma 
is  very  difficult.  The  X-ray  may  be  of  service. 

The  obvious  treatment  is  removal  of  the  necrotic  bone.  In  ex- 
ceptional cases  the  necrosis  has  been  so  extensive  that  amputation 
was  necessary. 


184  TUBERCULOSIS 

CHAPTER  XXVIII 

TUBERCULOSIS 

SURGICAL    TUBERCULOSIS 

By  this  term  we  include  those  varied  lesions  affecting  different 
structures,  which  are  directly  attributable  to  infection  by  the 
tubercle  bacilli,  and  which  require  surgical  intervention.  More  or 
less  strict  localization  is  the  rule,  so  that  often  drainage,  removal, 
or  sterilization  is  possible.  This  infectious,  communicable  disease 
was  at  one  time,  and  not  long  since,  considered  somewhat  uncom- 
mon during  infancy  and  early  childhood  and  although  many  con- 
ditions of  the  child's  system  were  described  as  predisposing  to 
tuberculosis  they  were  not  always  recognized  as  the  early  features 
of  the  disease  itself.  But  now  the  disease  occupies  an  important 
place  in  pediatrics  and  surgery  and  contributes  largely  to  infant 
mortality  and  childhood  suffering. 

Scrofulosis  was  a  term  that  was  freely  used  a  few  years  ago  to 
define  what  was  then  thought  to  be  a  definite  clinical  entity  but 
which  is  now  held  to  be  synonymous  with  tuberculosis.  It  implied 
that  the  affected  child  was  one  possessing  a  very  low  resisting  power 
which  was  generally  hereditary  and  particularly  prone  to  enlarge- 
ment of  the  lymphatic  glands.  Generally  these  indications  were 
present  after  the  third  and  before  the  tenth  year  of  life.  As  there 
was  always  present  a  general  malnutrition,  almost  innumerable 
symptoms  would  be  dependent  upon  this  and  upon  the  fact  that  the 
child  showed  a  marked  inclination  to  the  occurrence  of  chronic  in- 
flammation of  various  tissues  and  organs  under  the  influence  of  the 
slightest  irritation.  Whether  the  term  should  be  retained  to  still 
define  a  condition  is  still  a  question  among  many  writers. 

Status  lympliaticus  or  lymphatism  is  often  confounded  with 
tuberculosis,  but  as  it  is  fully  considered  in  another  section  (see 
page  155)  it  need  not  be  elaborated  here. 

Etiology. — TUBERCLE  BACILLI. — The  tubercle  bacillus  appears  in 


SURGICAL  TUBERCULOSIS  185 

the  tissues  as  a  short,  slender  rod  and  is  classed  by  many  with  the 
streptothrices  because  of  the  inclination  to  produce  branching  form 
in  culture  media.  Its  main  characteristics  are  its  slow  growth  on 
culture  media  and  its  difficult  development  under  the  influence  of 
either  high  or  low  temperatures.  Thus  we  see  that  the  bacilli  are 
parasitic  and  that  they  cannot  multiply  except  in  the  body  of  an 
animal.  It  is  a  well-known  fact  that  dried  sputum  retains  its 
virulence  for  from  two  to  four  months  but  that  exposure  to  sun- 
light or  even  the  milder  antiseptics  reduce  or  destroy  that  virulence. 

Action  of  the  Bacilli  in  the  Tissues. — Unless  destroyed  soon 
after  entering  the  body,  the  bacilli  multiply  rapidly  and  establish 
an  area  of  chronic  inflammation,  the  result  of  which  is  the  forma- 
tion of  granulation  tissue.  The  cells  of  this  focus  may  take  on  a 
characteristic  arrangement,  so  that  the  result  is  the  formation  of 
tubercles.  These  are  recognized  as  small  nodules,  produced  by  pro- 
liferation of  the  connective  tissue  and  in  the  course  of  their  develop- 
ment their  centers  undergo  caseation.  Microscopically,  a  fully  de- 
veloped tubercle  appears  with  its  center  necrotic  and  at  its  periphery 
there  are  numerous  giant  cells,  each  of  which  consists  of  a  mass 
of  degenerated  protoplasm  with  five  to  twenty  nuclei  at  its  border. 
The  necrotic  center  is  usually  surrounded  with  a  wall  of  epithelioid 
cells  and  round  cells  again  surround  these.  Then  comes  a  more  or 
less  complete  surrounding  with  mature  connective  tissues,  and  if 
this  be  completed  the  tubercle  is  said  to  be  encapsulated.  But 
occasionally  the  tubercle  appears  as  a  more  diffuse  affair  so  that 
we  encounter  cell  proliferation  over  a  considerable  area. 

CONDITIONS  PREDISPOSING  TO  INFECTION. — Of  first  importance, 
we  must  mention  any  condition  of  lowered  vitality  irrespective  of 
its  cause  and  independent  of  the  fact  as  to  whether  it  is  hereditary 
or  acquired.  Such  a  condition  renders  the  tissues  of  the  child  more 
easy  of  invasion  and  makes  the  multiplication  of  the  bacilli  more 
certain. 

The  Influence  of  Heredity. — Instances  of  congenital  tuberculosis 
have  been  reported  but  they  are  rare.  However,  it  is  a  well-estab- 
lished fact  that  tuberculosis  is  very  apt  to  occur  in  very  young 
children  and  in  them  shows  its  most  varied  forms,  but  this  does  not 


186  TUBERCULOSIS 

mean  that  the  disease  is  necessarily  congenital.  With  the  clearer 
understanding  of  the  disease,  the  influence  of  heredity  has  been 
minimized,  so  that  at  the  present  time  it  is  not  considered  as  an 
important  factor.  But  not  so  with  what  is  called  the  tuberculous 
diathesis. 

The  tuberculous  diathesis  plays  as  important  a  part  in  the 
etiology  of  tuberculosis  as  does  the  exciting  cause  itself.  Inde- 
pendent of  direct  infection  there  can  be  no  development  of  the 
disease.  In  the  presence  of  the  diathesis  it  requires  but  a  slight 
exposure  to  start  the  process.  Under  exactly  similar  conditions, 
the  diathetic  child  will  succumb,  while  the  non-diathetic  one  will 
escape.  Those  who  ignore  the  influence  of  a  constitutional  taint  that 
renders  the  child  peculiarly  vulnerable  to  tuberculosis  ignore  the 
evidences  which  have  come  through  the  careful  compilation  of  life 
insurance  tables  which  cover  thousands  of  cases  and  extend  over  a 
long  period  of  years.  The  family  history  then  becomes  an  impor- 
tant factor  in  the  recognition  of  the  disease  and  its  probable  occur- 
rence. 

Environment  is  an  important  factor  because,  while  lowered  re- 
sistance and  chronic  states  of  malnutrition  predispose  to  the  develop- 
ment of  tuberculosis,  environment  certainly  influences  nutrition  and 
resistance.  Poverty  with  its  consequent  evils  of  overcrowding,  poor 
ventilation,  insufficient  food,  and  absence  of  recreating  influences 
becomes  an  important  predisposing  cause.  The  geographic  dif- 
ferences in  the  disease  can  be  explained  mostly  upon  the  basis  of 
differing  environment. 

Age  has  a  very  distinct  influence,  for  tuberculosis  is  rare  during 
the  first  few  months  of  life,  but,  as  the  infant  grows  older,  the  pre- 
disposition becomes  relatively  stronger.  Probably  80  per  cent,  of 
the  cases  occur  between  the  second  and  fifth  year.  During  the 
first  two  years  the  disease  occurs  almost  exclusively  as  an  affec- 
tion of  the  bronchial  lymph  nodes  or  of  secondary  pulmonary  in- 
•  volvement.  After  two  years,  tuberculous  meningitis  is  more 
common  than  before,  and  affections  of  the  bones,  of  the  mesen- 
teric  lymph  nodes,  the  peritoneum,  and  the  intestines  are  not  un- 
common. 


SURGICAL  TUBERCULOSIS  187 

The  predisposition  of  sex  is  doubtful,  infants  and  children  of 
both  being  affected  apparently  in  equal  numbers. 

Racial  predisposition  is  noticeable  in  that  the  colored  race  is 
particularly  prone  to  the  disease. 

Predisposition  of  Previous  Disease. — This  we  consider  a  most 
important  factor.  Naturally  we  are  aware  that  any  exhausting 
disease  may  predispose  to  tuberculous  infection,  but,  irrespective 
of  this,  we  are  convinced  that  more  cases  of  tuberculosis  follow 
measles  and  pertussis  than  under  any  other  conditions.  Given  a 
child  who  by  a  favoring  constitution  or  association  with  the  disease 
has  been  liable  to  infection,  the  probabilities  of  such  infection  are 
great  if  measles  or  pertussis  occur.  And  this  appears  to  be  entirely 
independent  of  the  severity  of  these  two  diseases.  Personally,  we 
never  consider  a  child  safe  after  an  attack  of  either  disease  until 
it  has  been  thoroughly  examined  several  times  after  convalescence 
and  for  a  period  covering  at  least  three  months  in  measles  and  one 
year  in  pertussis. 

Traumatic  predisposition  seems  to  determine  the  localization  of 
the  disease  rather  than  its  occurrence  and  we  have  been  impressed 
with  the  fact  that  the  occurrence  of  an  injury  often  gave  the  sur- 
geon the  first  opportunity  to  discover  the  presence  of  the  disease. 
Bone  and  joint  injuries  are  particularly  liable  to  be  followed  by 
localization  of  the  disease  and  this  is  especially  true  if  the  injury 
be  a  slight  one.  But  in  most  instances  examination  of  the  child 
shows  that  there  is  a  tuberculous  affection  of  some  other  tissue 
present  and  that  the  injury  has  simply  aroused  localized  infection 
through  the  influences  of  lessened  resistance.  A  more  severe  injury 
calls  for  more  active  participation  by  the  system  in  the  processes 
of  immediate  repair  and  therefore  seems  to  render  strict  localiza- 
tion less  liable. 

Clinical  Manifestations  in  Children  and  Adults. — While  the  tissue 
results  are  practically  the  same  in  adults  and  children  when  infec- 
tion has  occurred,  still  there  are  some  marked  differences  of  invasion 
that  need  to  be  borne  in  mind.  In  dealing  with  adults,  the  mind 
naturally  turns  to  pulmonary  involvement  when  tuberculosis  is  men- 
tioned. But  to  the  pediatrist  or  the  pediatric  surgeon,  tuberculosis 


188  TUBEKCTJLOSIS 

means  first  some  glandular,  meningeal,  miliary,  bone,  joint,  perito- 
neal, or  diffused  lesion,  while  pulmonary  involvement  is  the  least 
prominent.  If  the  disease  occurs  as  an  acute  infection  in  the  child 
it  is  much  more  liable  to  become  generalized  than  in  adult  life. 
The  same  is  true  if  the  lesion  be  strictly  localized;  generalization 
is  the  rule  in  children. 

Clinical  Diagnosis  of  Tuberculosis. — The  clinical  diagnosis  of  tu- 
berculosis is  almost  always  possible  without  actual  demonstration 
of  the  presence  of  the  tubercle  bacilli,  but  on  the  other  hand  there 
are  so  many  conditions  which  in  their  onset  so  closely  approximate 
the  onset  of  tuberculosis  that  recognition  of  the  bacilli  becomes 
almost  indispensable.  It  is  true  that  while  the  tubercle  bacilli  are 
always  present  if  the  lesion  is  due  to  tuberculosis,  yet  their  demon- 
stration may  be  attended  with  so  much  difficulty  that  microscopic 
examination  is  unsatisfactory  and  uncertain.  Under  such  conditions 
resort  must  be  made  to  inoculation  of  the  suspected  material  into 
the  organisms  of  susceptible  animals.  In  fact,  in  an  examination 
for  the  bacilli  in  the  skeletal  structures  it  should  not  be  expected 
that  they  will  appear  in  anything  like  as  large  numbers  as  in  other 
situations,  as,  for  instance,  the  viscera.  In  fact,  a  considerable 
search  may  have  to  be  made  before  they  are  demonstrated.  We  have 
repeatedly  observed  instances  in  which  the  most  thorough  and  per- 
sistent search  failed  to  reveal  them  at  all.  This  fact  has  made  the 
inoculation  of  animals  a  necessary  procedure  in  many  cases. 

It  must,  of  course,  be  recognized  that  nothing  approaches  in 
importance  the  actual  demonstration  of  the  presence  of  the  tubercle 
bacillus  as  a  direct  means  of  diagnosis  and  this  needs  to  be  empha- 
sized when  the  indirect  methods  are  in  such  common  use  to-day. 

There  is  always  the  danger  that  the  indirect  methods  will  be 
given  an  undue  importance.  Tuberculin  is  used  in  the  indirect 
methods  of  diagnosis.  There  are  three  ways  of  using  it. 

(1)  SUBCUTANEOUS  TUBEBCULIN  TEST. — The  usual  method  is 
to  administer  1-10  milligram  for  the  initial  dose  and  double  that 
quantity  in  forty-eight  hours  if  no  reaction  occurs.  If  there  is 
slight  reaction  from  the  initial  dose,  the  second  one  is  of  the  same 
quantity  as  the  first  and,  if  the  second  reaction  is  more  marked 


SURGICAL  TUBERCULOSIS 


189 


than  the  initial  one,  this  constitutes  a  positive  reaction.  If  there  is 
no  reaction  from  the  first  two  doses,  a  third  and  still  larger  dose 
is  given  and  if  no  reaction  occurs  the  result  may  be  considered  as 
negative. 

The  child  should  be  under  observation  for  two  days  preceding 
the  test  and  four-hourly  temperatures  recorded.  After  the  adminis- 
tration, two-hourly  temperatures  are  recorded.  The  site  chosen  is 
not  very  important  but  the  usual  aseptic  precautions  are  necessary. 

Reaction  is  of  two  kinds :  general  and  local. 

General  reaction  includes  a  rise  in  temperature,  increased  pulse 
rate,  general  malaise,  and,  possibly,  some  headache.  The  really  valu- 


FIG.  74. — VON  PIRQUET  TEST  FOR  TUBERCULOSIS. 

In  making  the  three  scarifications,  the  control  should  be  left  at  the  top,  so  that  rubbing 
will  not  inoculate  it  from  the  other  two  scarifications. 

able  sign  is  the  elevated  temperature  and  it  occurs  between  the  sixth 
and  twelfth  hour  as  a  rule,  a  rise  of  more  than  one  half  degree 
being  regarded  as  positive  or,  at  least,  as  an  indication  for  other 
injections. 

The  local  reaction  cannot  always  be  observed,  but  if  present  is 
of  greater  value  than  the  general  signs.  It  varies  with  the  site 
of  the  disease,  so  that  in  pulmonary  tuberculosis  there  may  be  in- 
creased pain  or  cough,  while  in  tuberculous  glands  there  occurs  an 
increase  in  tenderness  and  swelling.  In  peritonitis  a  more  or  less 
active  diarrhea  may  be  set  up. 

(2)  CUTANEOUS  TEST  (Von  Pirquet). — The  site  chosen  should 
be  cleansed  carefully  and  dried.  Water  and  alcohol  must  be  avoided 


190 


TUBERCULOSIS 


as  they  cause  the  tuberculin  to  flow.  Three  scarifications  should 
be  made  (preferably  upon  the  inner  surface  of  the  arm),  sufficient 
to  partly  denude  the  surface  but  not  draw  blood.  These  scarifi- 
cations are  best  placed  three  to  four  inches  apart.  Into  two  of 
these  the  tuberculin  is  placed  and  protected  from  flowing  by  cotton, 
but  care  must  be  used  not  to  use  enough  cotton  to  completely  absorb 
the  tuberculin.  (For  Lincoln's  method  see  page  201.) 

A  positive  reaction  may  occur  after  a  few  hours  or  may  be  latent 


Fio.  75. — Mono  TEST  FOR  TUBERCULOSIS. 


for  several  days,  but  the  usual  appearance  is  within  twenty-four 
hours.  The  specific  reaction  begins  as  a  slightly  raised  red  spot 
spreading  from  the  scarification  with  the  diameter  of  the  papule 
usually  about  two-fifths  of  an  inch.  Exceptionally  the  center  is 
soft  but  never  pustular. 

The  Moro  Reaction. — In  this  test  the  skin  of  the  abdomen  or 
chest  is  rubbed  over  a  surface  of  four  square  inches,  with  a  pea- 
sized  piece  of  the  tuberculin  ointment.  Usually  on  the  second  day, 


191 

if  positive  reaction  is  present,  small  papules  appear  over  the  treated 
area.  These  disappear  within  a  week. 

(3)  OPHTHALMO-REACTION  (Calmette). — In  this  test  one  drop 
of  a  one  per  cent,  solution  of  tuberculin  is  instilled  into  one  eye 
of  the  patient  and  if  positive  there  occurs  redness  of  the  caruncle 
spreading  to  the  conjunctiva  with  the  production  of  tears  and  some 
discomfort.  In  some  instances  the  severity  of  this  reaction  becomes 
alarming.  Three  to  twelve  hours  is  the  usual  time  for  the  reaction 
to  appear  after  the  application.  Its  use  is  of  too  much  uncertainty 
and  fraught  with  too  great  danger  to  be  of  practical  service  in 
children. 

The  clinical  diagnosis  of  surgical  tuberculosis  is  based  in  general 
upon  the  formation  of  tuberculous  tissue  in  the  form  of  tubercles 
or  of  larger  areas  of  tuberculous  infiltration,  with  a  tendency  to 
caseation  (and  finally  softening  and  liquefaction),  absence  of  the 
usual  signs  of  acute  inflammation,  marked  tendency  to  the  invasion 
of  surrounding  tissues,  and  chronicity. 

General  Principles  of  Surgical  Treatment. — These  are  directly  in- 
fluenced by  the  marked  tendency  of  the  disease  to  become  general- 
ized in  childhood,  no  matter  what  or  where  the  primary  focus  may 
be.  The  results  are  two:  (1)  there  are  considerably  more  care  and 
thought  given  to  the  advisability  of  operative  interference,  and  (2) 
when  once  the  operation  is  determined  upon,  the  most  radical  pro- 
cedure seems  to  promise  the  best  protection  to  the  child. 

All  this  procedure  requires  a  nicety  of  judgment  and  a  thorough- 
ness of  examination  such  as  are  rarely  necessary  under  other  con- 
ditions. 

The  disease  as  it  affects  the  bony  structures  shows  a  decided  pre- 
dilection for  the  epiphysis  and,  in  this  particular,  we  observe  that 
it  is  quite  the  opposite  to  osteomyelitis,  which  usually  invades  the 
diaphyses.  Of  course,  we  must  not  be  unmindful  of  that  peculiar 
localization  which  is  almost  exclusively  confined  to  the  period  of 
infancy,  in  which  the  diaphyses  of  the  smaller  long  bones  of  the 
hand  and  foot  are  affected. 

It  is  the  spongy  portion  of  the  bone  that  bears  the  brunt  of  the 
primary  invasion,  as  a  rule.  The  interior  of  the  bone  is  not  un- 


192  TUBERCULOSIS 

commonly  the  site  of  the  original  infection,  and  in  that  case  we 
observe  a  tuberculous  osteomyelitis.  A  cold  abscess  may  result,  but 
more  often  we  encounter  a  caseous  focus  in  the  thickness  of  which 
there  may  be  a  sequestrum  which  differs  materially  from  that  of 
an  osteomyelitis,  in  that  it  is  not  so  hard  but  is  much  more  friable 
and  has  all  of  the  characteristics  of  a  caries. 

When  occurring  in  the  superficial  structure  of  the  bone,  there 
is  commonly  a  quite  strictly  localized  lesion  of  the  bone,  with  subse- 
quent extension  through  and  finally  over  the  periosteum  of  pus, 
and,  when  such  an  abscess  is  incised,  we  frequently  observe  that 
the  periosteum  is  intact  for  a  considerable  area. 

It  is  a  common  experience  that  the  tuberculosis  beginning  in 
bone  may  heal  spontaneously,  and  this  is  particularly  so  if  a  joint 
is  not  involved.  And  even  in  the  latter  case  resolution  sometimes 
takes  place.  But  the  tendency  is  toward  extension  and  progression 
and  therefore  every  case  must  be  treated  as  radically  as  the  cir- 
cumstances demand.  And  no  matter  how  careful  the  surgeon 
may  be  in  his  removal  of  all  seeming  diseased  tissue,  it  is  often 
impossible  to  be  sure  that  some  small  area  has  not  been  left  un- 
touched. 

In  infancy  and  childhood  the  onset  is  usually  not  that  of  an 
acute  arthritis,  but  it  occurs  as  a  slow  and  painless  condition. 
Despite  the  marked  tendency  toward  progression  and  extension,  we 
cannot  too  strongly  state  that  tuberculosis  of  the  bones  and  joints 
is  amenable  to  treatment,  and  the  results  are  remarkably  good,  con- 
sidering the  destruction  present. 

Treatment  of  Surgical  Tuberculosis.  —  GENERAL  TREATMENT.  - 
The  treatment  of  surgical  tuberculosis  involves  at  the  outset  the 
protection  of  others,  so  that  it  becomes  the  immediate  duty  of  the 
surgeon  to  destroy  any  infected  material  or  discharge  or  to  render 
it  incapable  of  infection.  Fire  is  the  best  means  of  protection  and 
all  materials  that  can  possibly  be  so  destroyed  should  be. 

Climate  is  of  considerable  importance  in  tuberculosis  affecting 
the  lungs,  but  in  the  disease  as  it  affects  the  bones,  the  glands,  and 
the  joints  it  has  little  if  any  influence.  And  so,  surgical  tubercu- 
losis does  not  demand  change  of  climate.  However,  the  influence 


SURGICAL  TUBERCULOSIS  193 

of  sunshine  and  fresh  air  is  nothing  short  of  remarkable.  It  can 
be  readily  placed  in  the  very  front  ranks  of  surgical  treatment  of 
tuberculosis,  constituting  considerably  more  than  one-half  of  the 
beneficial  influence  upon  the  lesions.  It  is  therefore  imperative 
that  the  child  spend  most  if  not  all  of  its  time  in  the  open  air,  and, 
when  conditions  permit,  all  the  hours  possible  should  be  spent  in 
the  direct  rays  of  the  sun.  It  is  of  course  desirable  that  the  air 
be  clean  as  well  as  fresh  and  free  from  dust  and  odor.  If  there 
is  a  preference  to  be  given  the  location,  the  seashore  should  be 
selected  as  best  adapted  to  meet  all  of  the  necessary  conditions. 

The  influence  of  direct  sunshine  is  of  very  large  importance  in 
the  treatment  and  when  feasible  the  portion  of  the  child's  body 
affected  with  the  disease  should  be  exposed  to  the  sun's  rays  oc- 
casionally during  the  day.  The  rays  have  a  considerable  pene- 
tration power,  retard  the  growth  of  the  bacilli,  and  favorably  affect 
the  nutritive  processes. 

The  influence  of  the  clean  fresh  air  is  largely  dependent  upon 
its  oxygen,  which,  when  inhaled  continuously,  stimulates  oxidation 
and  favors  reparative  processes.  Rest  of  the  affected  part  is  im- 
portant in  the  treatment.  This  very  fact  will  often  try  the  re- 
sources of  the  surgeon  because  its  enforcement  may  mean  confine- 
ment to  bed,  which  latter  may  be  undesirable.  Here  is  the  place 
for  a  display  of  judgment  and  the  child  should  be  given  the  benefit 
of  confinement  to  bed,  but  not  in  a  close  room  but  in  the  open  air. 
And  while  the  necessary  rest  which  is  entailed  helps  to  bring  about 
a  condition  characterized  by  the  temporary  retention  of  waste 
products  and  muscular  atony,  this  may  be  overcome  to  some  extent 
by  passive  exercises. 

Gentle  massage  administered  at  regular  intervals,  with  or  with- 
out oil,  and  passive  motion  of  all  parts  not  affected  will  usually 
suffice. 

The  eliminative  forces  of  the  skin,  bowel,  and  kidneys  must  be 
encouraged,  because  the  diet  must  be  necessarily  forced.  By  forcing 
the  diet  we  imply  that  all  the  nourishment  possible  should  be  given, 
but  with  the  most  careful  attention  to  the  digestive  capacity.  At  no 
time  should  the  desire  to  increase  the  nutrition  jeopardize  the  diges- 


194  TUBERCULOSIS 

tion.  However,  we  must  aim  to  give  a  diet  which  is  beyond  the 
needs  consequent  upon  waste;  in  a  word,  the  child  should  be  fully- 
fed  rather  than  underfed.  We  have  found  that  in  many  instances 
plain  milk  is  distasteful  and  it  is  the  rule  to  use  the  top  pint 
(after  the  cream  has  risen)  from  a  quart  bottle  and  dilute  it  with 
eight  ounces  of  plain  water,  any  cereal  water,  or  a  carbonated 
water  (suiting  it  to  the  child's  changing  tastes),  and  adding  one- 
half  to  one  dram  of  sugar  of  milk  to  each  two  ounces  of  the  mixture 
to  increase  the  carbohydrates.  This  plan  works  remarkably  well. 
There  is  no  one  plan  of  diet  that  will  favorably  affect  all  cases ;  the 
mixed  dietary  is  best  suited  to  the  indications.  Most  of  the  digestive 
disturbances  are  directly  traceable  to  one  large  meal,  and  therefore 
the  effort  should  be  made  to  control  this,  so  that  small  meals  are 
given  at  rather  shorter  intervals.  Eggs  are  very  valuable,  but  there 
is  a  mistaken  notion  that  the  whites  represent  all  of  the  nourish- 
ment; this  is  not  so,  the  whole  egg  should  be  given  and  preferably 
raw  or  very  lightly  cooked. 

Cod  liver  oil  is  also  used  as  a  food  and  its  judicious  administra- 
tion certainly  accomplishes  marked  results  in  many  instances. 

Milk,  eggs,  and  cod  liver  oil  have  been  specially  mentioned 
simply  because  they  are  preeminently  valuable  and  we  wish  to  speak 
briefly  of  the  methods  of  administration.  It  is  unnecessary  to  elab- 
orate upon  the  values  of  the  various  other  articles  of  diet,  for  their 
values  are  fully  considered  in  books  devoted  exclusively  to  that  pur- 
pose. All  that  is  necessary  now  is  to  reiterate  that  the  great  bulk  of 
the  treatment  consists  in  rest,  fresh,  clean  air  constantly  supplied, 
and  a  dietary  which  more  than  meets  the  immediate  needs  without 
in  any  manner  disturbing  the  child's  digestive  apparatus. 

Drug  administration  may  safely  occupy  a  very  minor  field. 
This  type  of  treatment  is  quite  restricted  to  the  control  of  unde- 
sirable symptoms  and  to  influencing  the  nutritive  and  reparative 
processes.  There  is  often  the  indication  for  a  well-selected  tonic 
or  even  a  stimulant,  and  the  inevitable  anemia  always  demands 
the  administration  of  arsenic  or  iron.  Then  we  have  recourse  to 
such  remedies  as  relieve  individual  accompaniments,  as  constipation, 
insomnia,  excessive  perspiration,  etc. 


SUEGICAL  TUBERCULOSIS  195 

LOCAL  TREATMENT  demands  rest,  as  has  been  stated,  and  this 
may  in  turn  require  some  restraining  apparatus.  During  the  acute 
and  painful  period  the  best  restraining  apparatus  is  undoubtedly 
plaster,  as  it  is  efficient  and  cannot  be  disturbed  by  the  child.  But 
as  quickly  as  the  circumstances  will  allow,  substitution  should  be 
made  by  using  leather  or  a  less  harsh  restraining  apparatus  than  the 
p]aster  cast. 

There  is  also  another  element  in  the  rest  treatment  that  we  must 
always  consider,  and  that  is  that  the  limb  is  not  only  placed  at 
absolute  rest,  but  also  in  a  good  position.  This  position  must  always 
approximate  as  closely  as  possible  the  position  of  the  particular  limb 
in  repose,  and  therefore  we  have  a  different  posture  for  each  joint. 
But  irrespective  of  rest  and  posture  there  are  several  drugs  that  pos- 
sess antituberculous  properties,  and  advantage  may  sometimes  be 
taken  of  these  in  the  local  treatment  of  the  lesion.  lodoform  or 
formalin  are  the  best  of  these  (see  page  197),  particularly  if  acting 
in  a  part  from  which  air  is  excluded.  Guaiacol  has  been  used  freely 
as  an  application  over  an  affected  part,  but  its  service  as  such  is 
doubtful.  Zinc  chlorid,  balsam  of  Peru,  oil  of  cinnamon,  ichthyol, 
and  mercury  ointment  have  all  won  advocates,  but  after  all  their 
use  is  very  limited. 

The  Finsen  light  and  the  X-ray  have  a  place  in  the  local  treat- 
ment of  the  disease,  being  particularly  useful  in  areas  of  localized 
tuberculosis,  and  especially  in  lupus,  in  which  they  effect  such  a 
decided  influence  that  they  should  be  used.  Lupus,  however,  is  ex- 
ceedingly rare,  but  when  encountered  it  is  usually  between  the  ages 
of  eight  or  nine  and  puberty.  The  adult  cases  are  generally  exacer- 
bations of  old  areas  which  were  present  in  childhood  but  which 
break  down  again  later. 

OPERATIVE  TREATMENT. — In  the  operative  treatment  the  prin- 
ciples involved  are  to  thoroughly  empty  and  remove  all  tuberculous 
foci  and  to  complete  the  destruction  of  any  bacteria  present. 

Unless  the  operative  procedure  can  be  radical  and  complete,  it 
should  be  deferred,  for  partial  operations  or  those  which  are  not 
sufficiently  radical  nearly  always  result  in  a  widespread  diffusion  of 
the  process  with  its  attendant  dangers  to  the  life  of  the  patient. 


196 


TUBERCULOSIS 


There  are  times  when  it  may  be  advisable  to  simply  open  and  drain, 
but  these  are  so  few  that  the  decision  to  do  so  must  only  come  after 
the  most  careful  consideration  of  all  the  factors  involved. 

The  incomplete  operation,  that  is,  with  the  removal  of  some  of 
the  tissue,  is  much  more  dangerous  than  incision  and  drainage,  be- 
cause partial  removal  opens  up  avenues  for  infection  which  were 
closed  previously  by  white  blood  corpuscles  or  fibrous  tissue. 

In  considering  any  operative  procedure  upon  foci  of  tuberculous 

infection  we  must  be  mind- 
ful of  the  fact  that,  just  as 
long  as  the  foci  are  circum- 
scribed in  the  depths  of  the 
tissue  without  contact  with 
external  air,  the  tubercle 
bacillus  is  the  one  that  is 
present  in  pure  culture. 
Once  exposed  to  the  air, 
and  the  staphylococci  and 
the  streptococci  added,  they 
bring  another  danger  to  the 
patient,  favoring  degenera- 
tion of  the  tuberculosis  and 
devitalizing  of  the  child. 

It  is  necessary  to  men- 
tion the  claim  of  Bier  that 
under  certain  circumstances 
the  production  of  active  or 
passive  hyperemia  will  favorably  influence  an  inflamed  area.  Just 
why  hyperemia  so  produced  should  influence  tuberculosis  is  still  dis- 
puted. The  method  of  passive  hyperemia  is  of  undoubted  value  in 
some  instances,  and  in  some  of  these  cases  its  value  is  great,  the  re- 
sults being  quick  and  marked.  There  is  no  question  but  that  in 
most  instances  it  lessens  the  pain,  and  if  the  applications  of  the  cups 
or  the  bandages  are  of  short  duration  and  but  slight  hyperemia  pro- 
duced, the  results  in  joint  tuberculosis  warrant  its  extended  trial. 
At  one  time  it  was  presumed  that  a  radical  operation  meant  only 


FIG.  76. — TUBERCULOUS  INFECTION  OF  THE 
BONES  OF  THE  FACE. 

On  the  right  is  seen  the  swelling  which  has  per- 
sisted for  two  months,  while  on  the  left  the 
tissues  have  broken  down  and  there  is  well 
marked,  just  in  front  of  the  ear,  a  point  at 
which  the  skin  is  ready  to  break.  This 
swelling  has  persisted  for  four  months. 


SURGICAL  TUBERCULOSIS  197 

amputation  or  resection.  Amputation  fortunately  is  practically  a 
relic  of  past  treatment.  Eesections  of  the  joints  are  open  to  the 
serious  objection  that  they  are  usually  followed  hy  persistent  sinuses 
and  continuous  suppuration  and  destruction  of  the  joint  does  not 
bring  about  any  certainty  of  a  cure  because  of  the  involvement  of 
the  neighboring  structures.  There  are  also  always  a  very  consider- 
able shortening  and  the  ever  present  danger  of  a  resulting  flail-like 
limb.  Resections  should  be  avoided  whenever  possible  in  infancy 
and  young  childhood  because  of  their  mentioned  dangers  and  the 
fact  that  simpler  operations  are  just  as  certain  in  their  ultimate 
results. 

In  the  operative  treatment  of  cold  abscesses  no  satisfactory  re- 
sults are  obtained  from  puncture  and  subsequent  injection  (of  iodo- 
form  and  ether)  unless  the  proper  time  is  chosen  for  the  procedure. 
If  the  skin  is  already  reddened  above  the  abscess  we  are  certain  to 
find  that  a  fistulous  tract  has  already  been  formed  and  puncture  is 
apt  to  bring  about  just  what  we  are  trying  to  avoid — septic  compli- 
cations. But,  on  the  other  hand,  if  opened  by  puncture  too  early, 
that  is,  before  fluctuation,  the  procedure  is  not  successful. 

In  performing  puncture  the  very  strictest  attention  must  be  paid 
to  every  detail  as  far  as  the  most  rigid  asepsis  is  concerned.  In 
performing  puncture  as  much  of  the  content  of  the  abscess  as  pos- 
sible should  be  removed  and  then  the  cavity  washed  out  with  a  sat- 
urated solution  of  boric  acid  until  the  return  is  quite  clear,  after 
which  the  iodoform  and  ether  may  be  injecteol.  The  amount  of 
iodoform  used  is  that  which  is  within  safe  limits  for  the  particular 
child  under  treatment.  As  ordinarily  used  iodoform  should  be 
mixed  with  ether  in  the  strength  of  1  to  10,  and  with  such  a  mix- 
ture the  penetration  to  the  deeper  structures  is  great,  the  expansion 
of  the  ether  as  it  evaporizes  carrying  the  iodoform  with  it. 

We  might  add  the  precaution  that  in  withdrawing  the  cannula 
from  the  trocar  sufficient  time  should  elapse  to  allow  the  ether  to 
vaporize  sufficiently  to  distend  the  cavity  of  the  abscess,  and  then 
its  escape  should  be  slow.  After  such  a  procedure  it  is  very  impor- 
tant that  the  part  subjected  to  the  operation  be  immobilized,  and 
preferably  with  a  plaster  apparatus.  Usually  it  is  necessary  to  re- 


198  TUBERCULOSIS 

peat  the  procedure  two,  three,  or  even  four  times,  but  not  infre- 
quently one  operation  is  all  that  is  needed.  The  interval  between 
punctures  should  be  close  to  three  or  four  weeks. 

Even  when  unsuccessful  as  far  as  a  cure  is  concerned  puncture, 
when  repeated,  gives  one  a  strong  clew  as  to  the  course  that  the  dis- 
ease is  taking  through  the  character  of  the  liquid  which  is  with- 
drawn. Occasionally,  despite  all  precautions,  a  sinus  will  form  and 
the  contents  of  the  sac  be  forced  out  through  the  opening  made  by 
the  trocar,  but  the  protective  influence  of  the  iodoform  seems  to 
prevent  any  septic  complications. 

When  puncture  fails  it  is  usually  because  the  sac  is  filled  with 
a  caseous  material  which  cannot  be  removed  entirely  by  this  method. 
In  such  cases  free  incision  and  cleansing  with  subsequent  phenol 
swabbing  are  efficient.  The  phenol  is  liquefied  with  glycerin,  and  the 
whole  cavity  swabbed  so  that  the  solution  is  in  contact  with  the  sur- 
faces for  one  to  three  minutes,  and  then  the  excess  washed  off  with 
alcohol.  Simple  aspiration  may  at  times  be  the  proper  method. 

Cutting  operations  should  not  be  undertaken  as  primary  meas- 
ures, but  should  be  reserved  for  such  cases  as  offer  little  or  no 
chance  for  improving  under  the  less  radical  methods.  We  must 
never  lose  sight  of  the  fact  that  the  child's  constitution  is  such  that 
it  aids  in  a  very  large  measure  all  conservative  measures  for  cure 
in  the  early  stages  of  this  disease. 

The  child's  tissues  tend  to  heal  unless  the  process  is  an  old  one, 
and  although  the  simpler  methods  may  take  a  much  longer  time  to 
ultimately  cure,  there  is  but  little,  if  any,  danger  of  the  process 
spreading  while  the  original  focus  is  under  treatment. 

TUBERCULIN  TREATMENT. — The  use  of  tuberculin  has  proven 
of  marked  success  in  many  instances,  and  its  use  should  be  more 
general.  It  is  easy  of  application,  and  in  children,  if  the  one  pre- 
caution is  taken  of  commencing  with  the  very  small  doses  so  as  to 
gage  the  susceptibility  of  the  individual  child,  no  harm  can  be 
done. 

The  chief  difficulty  has  been  that  every  child's  individual  sus- 
ceptibility differs,  and  there  is  no  way  of  telling  beforehand  just 
what  this  amounts  to  until  an  injection  is  given.  This  makes  ex- 


TTJBEBCULOSIS    OF   BONES    AND   JOINTS  199 

perimentation  with  vary  small  initial  closes  absolutely  necessary  for 
success,  and  with  this  precaution  established  we  have  in  tuberculin  a 
most  potent  and  valuable  adjunct  to  our  other  methods  of  treatment. 


Etiology  and  Pathology. — Tuberculous  lesions  are  essentially 
the  same  whether  they  occur  in  hard  or  soft  tissue.  The  active  irri- 
tant is  the  tubercle  bacillus  carried  by  the  blood  stream  and  lodged 
at  some  point  of  lowered  vital  resistance. 

The  tissue  reaction  to  this  irritant  is  similar  throughout  the 
body,  modified  only  by  the  density  of  the  tissues.  Hence,  when 
once  the  tubercle  bacilli  have  found  a  suitable  soil  we  note  in  bone 
as  in  other  tissues  the  same  orderly  pathological  events  which  in  an 
uninterrupted  march  present  successively  a  typical  picture,  viz. :  the 
formation  of  typical  tubercle,  typical  granulation  tissue,  typical 
caseation,  suppuration,  and  fistulization. 

It  is  well  to  remember  that  it  is  extremely  difficult  to  find  the 
specific  bacilli  in  bone  and  joint  lesions,  since  they  are  present  in  ex- 
tremely small  numbers,  and  even  the  most  expert  may  not  be  able 
to  discover  them.  The  inoculation  of  guinea  pigs  is  a  better  method 
of  demonstrating  the  specificity  of  the  lesion. 

We  note  that  in  acute  osteomyelitis  the  diaphyses  of  the  long 
bones  are  usually  affected;  in  tuberculosis  the  epiphyses  are  pre- 
ferred. It  is  only  very  exceptionally  that  tuberculosis  starts  in  the 
diaphysis.  The  one  exception  to  be  noted  is  tuberculosis  of  the 
smaller  long  bones  of  the  hand  and  foot,  which  is  known  as  "spina, 
ventosa"  and  frequently  seen  in  childhood. 

Again,  tuberculosis  has  a  predilection  for  the  spongy  tissue  of 
bone,  the  epiphyses  of  the  long  bones,  the  small  bones  of  the  carpus 
and  tarsus,  the  bodies  of  the  vertebras,  bones  of  the  cranium,  face, 
sternum,  etc. 

Tuberculosis  of  bone  is  always  a  secondary  character,  the  bacillus 


200  TUBERCULOSIS 

often  being  carried  from  a  distant  site  (bronchial  glands,  mucous 
membrane  of  nasopharynx,  intestinal  tract,  etc.). 

The  influence  of  trauma  plays  an  important  role,  for  there  must 
be  in  the  body  innumerable  potential  bacterial  factors  which  the 
resisting  power  of  the  organism  overcomes  and  thus  prevents  perma- 
nent lodgment. 

If  the  resisting  power  of  the  tissues  is  modified  by  traumatism 
there  are  prepared  a  suitable  soil  and  a  fertile  tuberculous  focus. 
Similarly  the  tissues  may  be  prepared  by  some  predisposition  like 
the  strumous  diathesis,  or  by  the  exhausting  effects  of  disease  such 
as  measles,  scarlet  fever,  pertussis,  etc. 

There  are  two  characteristics  of  tuberculoiis  infection : 

(a)  Gradual  destruction  of  the  tissue  first  attacked. 

(b)  Gradual  invasion  of  the  surrounding  tissues  always  in  the 
line  of  least  resistance. 

(a)  The  destruction  of  the  tissue  first  attacked  may  go  on  to 
caseation,  then  by  a  process  of  fibrosis  or  calcification  its  progress 
may  be  checked  and  healing  ensue. 

(b)  The  usual  course  is  gradual  invasion  of  the  surrounding 
tissue;  the  granulation  masses  dissolve  the  bone,  and  cavities  are 
formed  filled  with  cheesy  material  and  bone  sand  (caries).     In  other 
cases  the  granulation  tissue  cuts  off  the  vascular  supply  of  certain 
portions  of  the  bone  so  that  the  bone  dies  from  starvation  and  a 
sequestrum  is  formed  (necrosis). 

It  is  obvious  that  a  tuberculous  process  in  the  epiphysis  is  a 
menace  to  the  neighboring  joint — gradual  dissolution  of  the  bone 
tissue,  destruction  of  the  cartilage  and  synovial  membrane  are  the 
forerunners  of  joint  invasion,  and  the  joint  becomes  filled  with 
typical  granulation  tissue. 

With  the  liquefaction  of  the  cascating  masses  and  the  increased 
pressure  of  the  exudate,  the  pus  spreads  always  in  the  line  of  least 
resistance  until  it  reaches  the  surface  by  perforating  the  skin,  often 
at  a  remote  site  from  the  original  focus  (fistulization).  Thus  is 
formed  a  discharging  sinus. 

Symptoms. — Tuberculosis  of  bone  is  distinguished  by  its  chronic 
course  and   its   torpid   character.      It    begins  without   pain,   grows 


TUBERCULOSIS    OF    BONES    AND    JOINTS  201 

slowly,  and  is  accompanied  by  few  local  or  constitutional  disturb- 
ances. 

Tbe  chronicity  of  the  process  and  the  reflex  disturbance  are 
characteristic.  It  is  the  reflex  disturbance  whch  gives  a  varying 
picture  as  the  disease  manifests  itself  in  different  bones. 

The  essentials  of  this  reflex  disturbance  are  the  referred  pain, 
the  muscular  atrophy,  and  muscular  spasm.  The  referred  pain  is 
noted  in  hip  disease,  where  the  pain  is  felt  at  the  knee;  likewise  a 
lesion  at  one  end  of  a  long  bone  may  cause  pain  at  the  other. 

Muscular  spasm  must  be  regarded  as  an  effort  to  maintain  the 
part  in  a  state  of  physiological  rest.  This  tendency  is  specially 
noticeable  about  the  joints  where  muscular  spasm  gradually  leads 
to  fixation  and  deformity. 

In  the  small  pipe  bones  of  the  hand  and  foot  there  is  a  charac- 
teristic bulging  in  the  shaft  known  as  spina  ventosa  (characteristic 
in  children).  In  the  flat  bones  there  are  carious  areas  eaten  out, 
leaving  a  thin  bony  wall. 

Finally,  the  opening  of  the  abscess,  the  persistence  of  fistulous 
tracts,  fever,  emaciation,  and  diarrhea  are  evidence  of  general  in- 
fection. It  is  also  well  to  note  the  special  predisposition  in  children 
to  meningeal  complications. 

However,  as  Piechand  and  Denuce  have  observed,  the  generaliza- 
tion of  osseous  tuberculosis  in  children  is  not  frequent,  and  in  spite 
of  extensive  osseous  lesions  we  find  the  viscera  intact,  and  that  sec- 
ondary infections  are  more  to  be  feared  than  general  tubercular 
infections. 

Diagnosis. — Laboratory  demonstration  of  the  tubercle  bacilli  is 
not  practical.  Their  presence  is  proven  by  the  death  of  a  guinea  pig 
after  intraperitoneal  injection  of  the  products  of  inflammation. 

Great  assistance  will  be  afforded  by  a  properly  interpreted  X-ray 
picture  showing  the  slight  reaction  of  the  tissues  and  the  lack  of  the 
periosteal  wall. 

Finally  the  v.  Pirquet  skin  reaction  is  an  excellent  means  of 
diagnosis  in  small  children.  In  larger  children  who  have  already 
had  some  form  of  tuberculosis  the  findings  are  not  so  positive. 

The   technique   used,  is   that   recommended   by   Lincoln    as   de- 


:Tl£Ol-. 


202  TUBERCULOSIS 

scribed  by  Johnson  in  his  Surgical  Diagnosis :  "A  small  area  of 
skin  on  the  inner  side  of  the  forearm  or  other  convenient  situation 
is  sponged  off  with  ether.  A  tube  containing  twenty-five  per  cent, 
tuberculin  and  a  tube  containing  blank  solution  are  broken  off  at 
either  end.  Two  drops  of  the  tuberculin  are  blown  on  the  arm  about 
one  and  one-half  inches  apart,  and  one  drop  of  the  blank  solution 
between  the  two  drops  of  tuberculin.  The  scarifier  is  rubbed  off 
with  ether  and  the  edge  of  its  tip  is  revolved  about  four  times  in  the 
drop  of  tuberculin,  holding  the  scarifier  at  right  angles  to  the  skin, 
and  using  enough  pressure  to  slightly  dent  the  skin.  The  operation 
is  repeated  in  the  second  drop  of  tuberculin;  the  scarifier  is  again 
cleaned  with  ether,  and  the  spot  covered  with  blank  solution  is  then 
scarified.  The  only  immediate  result  will  be  three  tiny  depressions 
in  the  skin  in  the  center  of  the  three  drops  of  liquid." 

The  scarified  points  are  covered  with  a  vaccination  shield  until 
dry. 

The  reaction,  if  any,  usually  appears  at  the  end  of  twenty-four 
hours,  and  consists  of  a  red,  indurated  swelling  with  a  central  de- 
pression. It  subsides  in  from  one  to  four  weeks,  depending  upon 
its  severity.  There  are  no  constitutional  symptoms,  and  only  slight 
local  itching  and  tenderness.  As  Lincoln  observes,  the  more  ad- 
vanced the  disease,  that  is,  the  lower  the  reacting  power  of  the  in- 
dividual, the  smaller  the  percentage  of  positive  results  to  the  tuber- 
culin test.  The  positive  reactions  are  much  higher  in  cases  of  sur- 
gical tuberculosis  than  in  advanced  cases  of  pulmonary  tuberculosis. 
Other  means  of  diagnosis  by  similar  methods  are  considered  on 
page  188. 

It  will  be  necessary  to  differentiate  syphilitic  bone  infections. 
The  diagnosis  of  bone  syphilis  is  usually  not  difficult.  Its  predilec- 
tion for  certain  bones  (crest  of  tibia,  inner  border  of  ulna,  and  the 
clavicle),  the  tender  swellings  on  the  surface  of  the  bone,  the  osteo- 
copic  pains  occurring  at  night,  the  periosteal  exudation  forming 
exotoses  on  the  surface  of  the  bones,  specially  the  tibia,  produce 
characteristic  deformities,  and  as  Kirmisson  remarks — the  frequency 
of  this  deformity  about  the  tibia  has  made  it  true  that  the  tibia  is 
the  bone  par  excellence  for  the  diagnosis  of  hereditary  syphilis. 


TUBERCULOSIS    OF   BONES    AND    JOINTS  203 

Other  evidences  of  the  disease  may  confirm  the  diagnosis,  such  as 
notched  teeth  and  interstitial  keratitis,  and  the  occurrence  of  abor- 
tions or  premature  births  and  other  incidents  in  the  family  history. 
(See  page  150.) 

Finally  we  have  the  laboratory  diagnosis  by  Wassermann  reac- 
tion, demonstration  of  the  spirochete;  and  the  results  of  anti-syphi- 
litic treatment. 

Prognosis. — The  outlook  for  tuberculous  bony  lesions  in  children 
is  generally  favorable.  All  depends  on  the  child's  general  condition. 
Even  extensive  lesions  heal  if  the  general  condition  is  improved.  If 
the  tissues  cannot  master  the  disease  then  the  local  lesions  multiply 
and  the  disease  is  generalized. 

Treatment. — In  the  treatment  of  local  tuberculosis  too  much  em- 
phasis cannot  be  placed  upon  the  fundamental  principle  that  we  are 
treating  the  local  expression  of  a  general  condition.  The  local 
lesions,  whether  in  bone  or  joint,  are  only  the  local  evidence  of  a 
debilitated  body.  It  is  not  merely  a  diseased  bone  or  joint  that 
needs  treatment,  it  is  a  sick  child — hence  the  folly  of  that  surgical 
attitude  which  extols  the  knife  and  neglects  the  soil  in  which  the 
disease  is  thriving.  Operation  may  remove  an  infected  area,  but  if 
the  body  continues  sick  the  disease  will  appear  in  another  place. 
As  well  attempt  to  improve  the  garden  soil  by  eradicating  a  single 
weed. 

Bone  tuberculosis  is  always  a  secondary  process;  even  with  the 
most  radical  operation  the  primary  focus  still  remains;  hence,  the 
treatment  of  all  local  tuberculous  lesions,  especially  those  of  bone  and 
joint  in  children,  is :  General  treatment  of  the  child  to  so  improve 
the  tissues  that  the  tubercle  bacilli  will  cease  to  thrive,  and  this  gen- 
eral treatment  must  be  assisted  by  such  local  surgical  treatment  as 
will  prevent  local  extension,  secondary  infection,  and  diminished 
function. 

The  whole  problem  in  surgical  tuberculosis  is  to  increase  the 
vital  resistance  of  the  organism  with  the  least  amount  of  local  dam- 
age. In  children  the  knife  is  the  last  resort,  and  extensive  openings 
of  tuberculous  foci,  curettings,  and  all  radical  procedures  are  to  be 
avoided. 


204  TUBERCULOSIS 

GENERAL,  TREATMENT. — The  tissues  of  the  patient  are  improved 
by  proper  nutrition,  unlimited  sunshine,  and  fresh  air. 

TUBERCULIN  has  given  excellent  results  in  bone  tuberculosis  and 
should  be  given  in  small  doses  gradually  increased. 

LOCAL  TREATMENT  should  consist  in  the  application  of  those 
measures  which  are  constructive.  Destructive  measures  (knife, 
curette)  should  be  used  only  as  a  last  resort.  First :  Place  the  dis- 
eased part  in  a  condition  of  physiological  rest,  in  such  a  position  as 
will  permanently  result  in  the  least  amount  of  functional  disabil- 
ity. Second:  Increase  the  blood  supply  to  the  diseased  area  by 
making  an  artificial  chronic  congestion  after  the  method  of  Bier. 
The  congestion  is  produced  by  the  application  of  an  elastic  bandage 
above  the  point  involved  which  shuts  off  the  venous  circulation  with- 
out interfering  with  the  arterial  flow.  This  treatment  may  be  ap- 
plied from  fifteen  minutes  to  one  hour  at  a  time — toleration  of  the 
elastic  bandage  increases  with  use,  and  later  it  can  be  borne  for 
longer  periods.  This  method  has  produced  marked  improvement  in 
many  cases.  It  should  be  the  routine  treatment  in  cases  where  it  can 
be  effectually  applied. 

Closed  tuberculous  abscesses,  whether  they  are  far  removed  from 
the  bone  focus  or  not,  are  not  to  be  opened;  they  should  always  be 
aspirated  and  the  contents  removed  by  suction.  Aspiration  should 
be  repeated  until  the  discharge  becomes  serous  in  character,  then 
inject  a  few  drops  of  a  five  per  cent,  emulsion  of  iodoform  and 
glycerin  or  a  20  per  cent,  solution  of  formalin  in  glycerin  and  apply 
sterile  compresses  over  the  abscess  area. 

INDICATIONS  FOR  OPERATIVE  TREATMENT. — When  the  X-ray 
demonstrates  the  presence  of  a  sequestrum  it  should  be  carefully  re- 
moved to  avoid  chronic  suppuration.  Nothing  but  the  dead  bone 
should  be  removed,  curetting  should  be  avoided,  and  the  remaining 
cavity  filled  with  a  five  per  cent  emulsion  of  iodoform  and  glycerin. 
Any  further  treatment  should  be  on  conservative  lines.  This  offers 
the  best  chance  of  relief. 

When  the  tuberculous  foci  threaten  a  joint  an  extracapsular 
opening  should  be  considered.  Secondary  infections  and  extensive 
suppurations  require  radical  operative  relief. 


205 


TUBERCULOSIS  OF  JOINTS 

Pathology. — Joint  tuberculosis  is  one  of  the  most  frequent  dis- 
eases of  childhood,  and  is  responsible  for  a  large  number  of  defor- 
mities. All  visceral  cavities  are  really  joint  cavities,  and  tuber- 
culosis of  the  articulations  presents  much  the  same  pathological  anat- 
omy as  is  found  in  pulmonary  tuberculosis.  The  spongy  extremity 
of  the  bone  may  be  compared  to  the  lung,  the  synovial  sac  to  the 
pleura.  Thus  the  joint  may  be  infected:  (a)  By  a  spread  of  the 
disease  from  the  neighboring  epiphysis;  (b)  by  infection  of  the 
synovia  through  the  blood  stream.  In  either  event  the  onset  is  slow 
and  insidious  and  the  subsequent  progress  exceedingly  chronic.  Irri- 
tation of  the  synovial  membrane  gives  rise  to  serous  exudate  (tuber- 
culous hydrops),  or  the  joint  is  invaded  with  the  typical  granula- 
tion tissue  which  caseates,  suppurates,  and  slowly  disintegrates  the 
joint  structures.  Finally  a  joint  abscess  may  form,  the  pus  finds 
its  way  through  the  thickened  capsule  and  fistulization  ensues.  A 
late  feature  of  the  disease  may  be  a  pathological  dislocation  due  to 
muscular  spasm. 

The  dry  form  of  joint  tuberculosis  (arthritis  tuberculosa  sicca), 
which  is  characterized  by  the  absence  of  fluid,  is  rarely  seen  in  chil- 
dren ;  it  occurs  most  frequently  in  persons  of  advanced  years. 

In  children  there  is  usually  a  primary  exudate,  and  the  joint 
is  slowly  filled  with  typical  granulation  tissue. 

The  external  appearance  of  the  joint  is  characterized  by  the 
obliteration  of  its  contour,  which  is  replaced  by  a  local  swelling  cov- 
ered by  the  white,  tense,  shiny  skin  (white  swelling). 

The  struggle  of  the  tissues  to  master  the  infection  is  shown  in 
their  eifort  to  wall  off  the  focus  either  by  the  formation  of  a  fibrous 
capsule  or  a  sclerotic  bone  capsule.  Not  only  is  the  joint  itself  in- 
volved in  the  tuberculous  process,  but  most  conspicuous  are  the 
alterations  which  occur  in  the  muscles  which  move  the  joint  and  the 
vicious  positions  which  are  ultimately  established. 

The  surrounding  muscles  may  be  directly  invaded  by  the  tuber- 
culous process,  a  conspicuous  example  of  which  is  the  psoas  abscess 
often  seen  in  Pott's  disease.  Associated  with  these  joint  lesions  is 


206  TUBEKCULOSIS 

an  invariable  muscular  atrophy,  not  merely  the  atrophy  of  disuse,  but 
a  distinct  degeneration  of  the  muscle  directly  attributable  to  the 
disease. 

Finally,  the  effort  of  nature  to  fix  the  joint  in  the  position  of 
greatest  physiological  rest  gives  rise  to  muscular  spasm,  muscular 
contraction,  which  in  time  becomes  fixed;  the  muscles  shorten, 
undergo  fibrous  degeneration,  and  the  joint  assumes  a  definite  vicious 
position. 

Prognosis. — The  prognosis  in  children  is  more  favorable  than  in 
adults.  In  only  a  small  percentage  of  cases  does  the  process  become 
generalized  or  are  the  viscera  involved  (meningitis,  amyloid  degenera- 
tion). 

As  to  the  integrity  of  the  joint — it  is  extremely  rare  that  treat- 
ment is  begun  sufficiently  early  to  restore  normal  function.  The 
very  process  by  which  the  disease  is  conquered  (formation  of  fibrous 
tissue)  is  the  price  of  the  cure  which  must  be  paid  in  an  ankylosis, 
either  complete  or  incomplete.  It  should  be  well  understood  by  the 
parents  that  the  best  they  can  expect  in  the  treatment  of  a  tuber- 
culous joint  is  ankylosis  in  a  position  most  favorable  to  function. 

Symptoms. — Early  diagnosis  lessens  subsequent  disability  and 
shortens  the  course  of  the  disease. 

Among  the  early  symptoms  is  pain,  exaggerated  by  fatigue  and 
movement,  sometimes  localized,  at  other  times  reflected.  Note  the 
reflected  pain  at  the  knee  in  early  hip  disease — one  of  the  charac- 
teristics of  early  pain  is  the  fact  that  it  disappears  when  the  patient 
lies  down. 

Tenderness  may  be  elicited  by  direct  pressure  on  the  affected 
epiphysis  or  by  percussion.  Next  follows  loss  of  function — the  pa- 
tient limps  in  his  effort  to  protect  the  joint  from  the  impact  in  walk- 
ing. The  joint  is  fixed  by  muscular  spasm — an  early  sign  of  great 
diagnostic  value.  Then  follow  muscular  contraction  with  definite 
vicious  attitude,  muscular  atrophy,  enlargement  of  the  joint,  glandu- 
lar involvement,  abscess  formation,  fistulization,  pathological  di~- 
location,  etc.  The  later  stages  of  the  disease  show  their  effects  upon 
the  general  health  in  the  secondary  anemias  and  the  general  toxemia. 

Errors   in   diagnosis   will  be   avoided   by   examining  the   child 


TUBEECULOS1S    OF    BONES    AND    JOINTS  207 

stripped  of  its  clothing,  paying  careful  attention  to  all  the  joints 
and  comparing  the  diseased  with  the  corresponding  healthy  joint. 
The  diagnosis  of  joint  tuberculosis  must  be  considered  in  the  special 
consideration  of  the  separate  joints  since  the  clinical  picture  changes 
as  the  disease  manifests  itself  in  the  different  joints. 

Treatment. — What  has  been  said  of  bone  tuberculosis  applies 
equally  to  tuberculous  joints — too  much  emphasis  cannot  be  placed 
upon  the  fundamental  principle  that  we,  are  treating  the  local  ex- 
pression of  a  general  condition.  As  we  have  stated,  the  local  lesions, 
whether  in  bone  or  joint,  are  only  the  local  evidence  of  a  debilitated 
body.  It  is  not  merely  a  diseased  bone  or  joint  that  needs  treatment, 
it  is  a  sick  child — hence  the  folly  of  that  surgical  attitude  which 
extols  the  knife  and  neglects  the  soil  in  which  the  disease  is  thriving. 
Operation  may  remove  an  infected  area,  but  if  the  body  continues 
sick  the  disease  will  appear  in  another  place.  As  well  attempt  to 
improve  the  garden  soil  by  eradicating  a  single  weed. 

The  treatment  of  all  tuberculous  lesions  of  the  joints  in  children 
is :  General  treatment  of  the  child  to  so  improve  the  tissues  that  the 
tubercle  bacilli  will  cease  to  thrive,  assisted  by  such  local  surgical 
treatment  as  will  prevent  local  extension,  secondary  infection,  and 
diminished  function. 

GENERAL  TREATMENT. — The  tissues  of  the  patient  are  improved 
by  proper  nutrition,  unlimited  sunshine,  and  fresh  air.  The  use  of 
tuberculin  has  been  followed  by  excellent  results  (see  technique, 
p.  198). 

LOCAL. — First  and  most  foremost  it  is  essential  to  secure 
physiological  rest  in  a  good  position  which  will  necessitate  correc- 
tion of  the 'vicious  attitude,  immobilization  of  the  articulation,  and 
the  application  of  extension  to  keep  the  diseased  joint  surfaces 
apart. 

Second:  The  blood  supply  to  the  diseased  area  should  be  in- 
creased by  producing  an  artificial  chronic  congestion  after  the 
method  of  Bier.  The  congestion  is  produced  by  the  application  of 
an  elastic  bandage  above  the  part  involved  which  shuts  off  the  venous 
circulation  without  interfering  with  the  arterial  flow.  This  treat- 
ment may  be  applied  from  fifteen  minutes  to  one  hour  at  a  time — - 


208  EEYS1PELAS 

toleration  of  the  elastic  bandage  increases  with  use,  and  later  it  can 
be  borne  for  longer  periods.  This  method  has  given  excellent  results. 
It  is  obvious  that  this  method  is  applicable  to  joints  below  the  hip 
and  shoulder. 

Joint  abscesses  are  not  to  be  opened,  they  should  always  be 
aspirated  and  their  contents  removed  by  suction,  followed  by  the 
injection  of  five  per  cent,  emulsion  of  iodoform  and  glycerin,  or 
a  two  per  cent,  solution  of  formalin  and  glycerin. 

The  indications  for  OPERATIVE  TREATMENT  will  be  discussed 
under  treatment  of  special  joints. 


CHAPTER  XXIX 

ERYSIPELAS 

Etiology. — This  disease  is  a  wound  infection  which  results  in  a 
rapidly  spreading  inflammation  of  the  skin  and  the  mucous  mem- 
branes. The  size  of  the  wound  has  no  bearing  upon  the  extent  or 
virulence  of  the  disease  for  with  the  slightest  abrasion  there  may 
be  as  severe  a  type  of  the  disease  as  with  a  more  extended  injury 
to  the  tissues.  While  with  our  present  knowledge  it  is  possible  to 
lay  much  stress  upon  climatic  influence  in  the  prevalence  of  the 
disease,  still  we  must  acknowledge  that  during  the  severer  seasons, 
particularly  the  cold  and  damp  periods,  or  when  there  are  sudden 
and  rapid  variations  of  temperature,  the  disease  is  far  more  apt 
to  occur. 

The  direct  cause  is  the  entrance  of  streptococci  into  the  skin 
and  this  streptococcus  does  not  differ  from  the  streptococcus  pyogenes. 
Therefore  we  must  accept  the  facts  established  repeatedly  by  animal 
experimentation  and  confirmed  by  clinical  experience,  that  there 
is  no  specific  agent  of  erysipelas  but  that  the  disease  may  be  typically 
produced  in  man  by  cocci  that  are  not  obtained  from  a  case  of 
erysipelas  and  that  one  and  the  same  agent  may  produce  erysipelas 
or  suppuration. 

This  knowledge  is  of  vast  clinical  value  and  explains  readily 


SYMPTOMS  209 

many  of  the  perplexing  problems  of  infection  which  were  unknown 
before.  The  organism  enters  the  lymph  spaces  and  then  migrates 
further  into  the  tissues. 

Regarding  the  direct  mode  of  transmission,  we  know  that  there 
must  be  the  most  careful  isolation  of  the  child  affected  with  the 
disease,  as  he  is  a  constant  source  of  danger  to  those  with  whom 
he  comes  in  contact.  The  room  in  which  the  child  is  confined, 
the  articles  contained  therein,  the  attendants,  all  may  become  active 
agents  in  the  dissemination  of  the  disease,  unless  the  most  thorough 
care  and  disinfection  are  carried  out. 

Incubation. — The  period  of  incubation  is  still  unknown  in  man 
because  we  have  only  the  date  obtained  from  artificial  transmission 
experiments  to  aid  us.  But  from  these  it  would  seem  that  there 
is  a  period  during  which  there  are  no  appreciable  symptoms  present, 
and  this  period  is  between  one  and  three  days.  However,  there  are 
instances  in  which  everything  indicates  as  long  a  period  as  seven 
or  eight  days. 

Symptoms. — The  symptomatology  is  influenced  by  the  age  of  the 
child  and  whether  it  occurs  as  a  primary  or  secondary  affection. 

In  the  new-born  the  umbilical  region  shows  a  slight  redness 
which  spreads  rapidly  downward  over  the  abdomen  or  even  down 
the  legs.  The  parts  affected  are  edematous  and  feel  warm.  Within 
a  few  hours  the  redness  and  edema  may  have  spread  over  a  large 
surface,  but  it  is  rare  that  it  ever  spreads  up  over  the  upper  por- 
tion of  the  abdomen  or  the  chest. 

There  is  no  chill  and  rarely  any  marked  constitutional  dis- 
turbance to  indicate  the  onset  of  the  disease.  Fever  is  not  always 
present  and  when  it  occurs  the  rise  of  the  temperature  is  usually 
very  gradual  although  in  some  instances  it  may  eventually  become 
very  high.  In  the  new-born  the  edema  is  always  more  marked  than 
in  later  life,  but  the  sharply  defined  borders  of  the  eruption  are 
less.  In  older  children  the  disease  follows  quite  closely  the 
symptomatology  of  adult  life,  but  of  course  with  the  modifications 
which  come  with  the  immaturity  of  the  affected  child. 

Occurring  as  a  primary  affection  there  is  usually  a  chill  or 
something  which  closely  approximates  the  chill  and  this  is  accompa- 


210  ERYSIPELAS 

nied  by  a  decided  rise  in  the  temperature  and  some  digestive  de- 
rangement (usually  vomiting).  In  general,  when  present,  the 
temperature  is  of  a  remittent  or  intermittent  type  and  while  the 
height  of  the  temperature  seems  to  be  independent  of  the  severity 
of  the  disease  (low  temperatures  being  observed  in  the  severe  cases 
as  well  as  in  the  mildest  ones),  yet  the  influence  which  such  a 
temperature  is  having  upon  the  general  condition  of  the  particular 
child  will  be  of  value  in  prognosis. 

Occurring  as  a  secondary  affection  (as  during  the  course  of 
scarlet  fever),  there  are  usually  no  chill  and  no  decided  rise  of 
temperature,  so  that  erysipelas  in  such  instances  may  readily  be 
overlooked  for  a  time.  For  example,  if  a  child  suffering  from 
scarlet  fever  or  sepsis  become  affected  with  erysipelas,  the  tempera- 
ture will  be  elevated  only  one  or  perhaps  two  degrees  by  the  second- 
ary affection  and  this  will  occur  without  a  chill  or  chilly  sensations 
or  any  other  marked  constitutional  disturbance  which  would  indicate 
its  presence.  Therefore  it  is  only  by  the  most  watchful  care  and 
observation  that  the  surgeon  will  make  the  early  diagnosis  of  this 
disease  in  the  presence  of  other  infections  and  even  then  only  by 
an  appreciation  of  the  local  symptoms  and  minor  constitutional 
symptoms  which  are  suggestive.  Some  children  (those  of  more  than 
the  average  intelligence)  may  complain  of  indefinite  pains  in  the 
muscles  or  a  new  sense  of  weariness  which  is  not  accounted  for  by 
anything  connected  with  the  primary  disease.  In  nearly  every 
instance  there  is  increased  restlessness  or  fretfulness  and  these  are 
very  apt  to  be  attributed  to  other  causes  than  the  onset  of  erysipelas. 

However,  it  is  the  local  signs  that  are  of  most  value  and  in 
general  the  disease  is  evidenced  by  the  appearance  of  one  or  more 
closely  associated  reddened  spots,  distinctly  elevated  above  the  level 
of  the  skin.  These  may  have  the  sensations  of  burning  or  itching. 
But  as  the  disease  develops  this  sensation  is  replaced  by  one  of 
tension.  The  characteristic  appearance  is  a  markedly  reddened 
surface,  with  sharply  defined  borders,  the  skin  being  swollen  and 
hot  and  often  with  a  peculiar  luster.  From  this  principal  focus 
many  smaller  processes  may  advance  until  a  large  area  is  covered. 

According  to  the  situation  of  the  eruption  and  also  its  intensity, 


SYMPTOMS  211 

there  are  modifications  in  its  appearance,  so  that  on  the  skin  of 
the  head,  for  example,  there  is  uniform  and  marked  infiltration, 
while  in  other  situations  and  notably  those  in  which  the  bony 
structures  come  close  to  the  surface  there  are  apparent  islands  of 
inflammatory  edema. 

This  cutaneous  inflammation  usually  reaches  its  height  within 
two  or  three  days,  after  which  there  are  a  gradual  decline  and  disap- 
pearance which  depend  somewhat  upon  the  virulence  and  the  loca- 
tion of  the  affection.  If  attacking  the  face  and  head  and  uncompli- 
cated, the  whole  process  subsides  in  about  seven  or  eight  days, 
while  on  the  other  hand  if  the  disease  has  shown  a  tendency  to 
advance  from  one  point  to  another  it  may  be  several  weeks  before 
all  signs  of  it  subside. 

There  are  forms  of  the  disease  which  follow  a  very  acute  course, 
but  these  are  the  unusual  cases.  In  such  instances,  there  are  all 
the  symptoms  of  a  marked  sepsis,  or  early  in  the  course  of  the 
disease  there  may  be  severe  headache  with  clouding  of  the  sensorium 
or  marked  delirium.  Other  cases  merely  exhibit  an  early  and  pro- 
found state  of  coma  which  resists  all  the  usual  efforts  to  combat  it. 

Erysipelas  of  the  mucous  membranes  deserves  special  mention 
because  it  leads  so  often  to  the  severest  symptoms  and  complica- 
tions. It  is  not  uncommon  to  find  that  erysipelas  of  the  throat  or 
nose  has  preceded  the  evidences  of  cutaneous  inflammation.  But  it 
is  not  this  common  experience  that  is  most  important,  but  that 
rarer  condition  in  which  the  larynx  becomes  affected  secondarily 
and  produces  very  rapidly  such  dyspnea  and  stenosis  as  are  danger- 
ous to  the  life  of  the  child.  In  such  conditions  early  death  is  often 
only  averted  by  early  tracheotomy. 

And,  further  than  this,  the  wide  extension  of  the  inflammation 
may  result  in  severe  bronchitis  or  pneumonia,  which  latter  is  accom- 
panied by  very  slow  hepatization  and  a  marked  splenic  tumor  and 
is  extremely  dangerous  to  life.  There  is  in  erysipelas  a  marked 
tendency  to  relapses,  for  no  immunity  is  acquired  by  once  having 
the  disease.  On  the  other  hand,  there  seems  to  be  a  decided  tendency 
in  some  children,  after  once  having  the  disease,  to  continue  to  be- 
come affected  during  successive  years. 


212  ERYSIPELAS 

But,  irrespective  of  this  tendency  to  remote  relapses,  there  is 
also  a  tendency  to  immediate  relapse,  so  that  a  few  hours  after 
subsidence  of  all  symptoms  the  affection  may  again  appear,  and 
this  may  be  repeated  several  times. 

Diagnosis. — The  diagnosis  does  not  offer  much  difficulty  after  the 
inflammation  has  appeared  upon  the  skin.  The  painful  area  is  hot, 
of  a  rose-red  color,  and  exhibits  an  edematous  swelling  which  is 
quite  sharply  defined  from  the  rest  of  the  healthy  tissue,  so  that 
the  demarcation  is  marked.  But  evdn  with  the  usually  well- 
developed  symptomatology  which  is  encountered  the  disease  may 
readily  be  confounded  with  other  conditions.  One  of  the  most  per- 
plexing problems  at  times  is  to  differentiate  between  a  simple 
erythema  and  erysipelas.  The  former  depends  upon  a  transitory 
hyperemia  of  the  skin  and  the  chief  points  of  difference  are  that 
it  runs  its  course  without  a  marked  elevation  of  the  temperature 
or  without  any  decided  pain  or  swelling. 

Erythema  exudativa  multiforme  may  exhibit  lesions  of  limited 
extent,  and  the  same  be  associated  with  more  or  less  severe  general 
symptoms,  simulating  erysipelas,  but  the  etiologic  factors  are  en- 
tirely dissimilar  and  this  is  also  a  rather  rare  condition  in  child- 
hood, while  erysipelas  is  common. 

A  diffuse  phlegmonous  inflammation  simulates  erysipelas  closely 
as  it  is  characterized  by  redness  and  swelling  with  inflammation, 
but  in  these  diffuse  inflammations  the  redness  is  much  darker  than 
in  erysipelas,  is  not  limited  in  any  direction,  and  the  skin  has  a 
hard,  board-like  feel.  If  erysipelas  attacks  the  mucous  surfaces,  its 
diagnosis  remains  very  uncertain  until  the  time  of  its  spread  to 
the  skin,  for  it  is  readily  seen  that  the  associated  symptoms  of 
glandular  swelling,  rapid  rise  in  temperature,  splenic  enlargement, 
and  dysphagia  are  common  to  other  inflammations  of  the  throat. 

Prognosis. — The  prognosis  in  the  newly  born  is  always  unfavor- 
able ;  cases  under  one  year  almost  invariably  die.  Even  during  the 
first  year  of  life  any  form  of  the*  disease  must  be  considered  danger- 
ous. After  the  period  of  infancy,  in  simple  uncomplicated  cases, 
the  prognosis  is  favorable,  although  it  must  always  be  recalled  that 
the  toxic  action  of  the  organism,  acting  upon  the  heart  in  the  iinnia- 


TREATMENT  213 

ture,  adds  a  considerable  element  of  danger  which  is  not  easy  to 
overcome.  Occurring  in  an  ill-nourished  child,  even  as  a  primary 
affection,  there  is  great  danger  to  life.  As  a  secondary  affection, 
occurring  in  a  child  already  weakened  by  the  primary  disease,  the 
prognosis  is  unfavorable.  Laryngeal  involvement  is  always  a  grave 
matter,  usually  demanding  operative  interference,  which  the  child 
cannot  always  stand. 

Treatment. — The  treatment  is  mainly  prophylactic,  for  we  know 
that  the  child  affected  or  convalescent  from  the  disease  is  a  great 
source  of  danger.  Further  than  this,  we  know  that  the  streptococcus 
producing  the  disease  is  long  lived  and  that  this  microorganism 
remains  for  a  great  length  of  time  about  the  room  in  which  the 
child  was  confined  and  retains  most  of  its  virulence. 

It  is  necessary  then  to  isolate  all  affected  individuals  and  insti- 
tute such  a  scheme  of  isolation  and  disinfection  as  will  adequately 
meet  the  requirements.  It  is  unnecessary  to  enumerate  these  pre- 
cautions, which  are  similar  to  those  used  in  other  infectious  diseases 
of  a  high  virulence,  but  in  addition  for  adequate  prophylaxis  there 
must  be  the  most  careful  toilet  of  the  eyes,  the  ears,  and  the  nose 
and  mouth. 

LOCAL  TREATMENT  involves  the  use  of  such  applications  as  will 
limit  the  activity  of  the  cocci  and  therefore  excellent  results  are  ob- 
tained from  such  local  applications  as  25  per  cent,  to  50  per  cent, 
ichthyol  with  collodium.  To  be  of  service,  the  antiseptics  in  com- 
mon use  must  be  applied  in  strong  solutions  and  therefore  their  use 
is  very  much  restricted  in  children  because  of  the  unfavorable  action 
on  the  skin.  A  1  or  (in  older  children)  a  2  per  cent,  solution 
of  carbolic  acid  (Phenol),  with  exclusion  of  air,  may  be  of  service, 
particularly  if  glycerin  be  added  (about  10  per  cent.),  or  1  per  cent, 
corrosive  sublimate  with  glycerin  may  be  used. 

The  GENERAL  TREATMENT  aims  chiefly  to  prevent  diminished 
heart  action  with  subsequent  collapse.  To  combat  this  there  should 
be  the  early  institution  of  forced  feeding  with  small,  frequent,  and 
concentrated  meals  and  the  administration  of  a  cardiac  stimulant 
and  an  iron  tonic.  As  a  cardiac  stimulant,  the  tincture  of 
strophanthus  meets  every  requirement  without  the  danger  of  up- 


214  TETANUS 

setting  the  digestion.  As  an  iron  tonic,  nothing  compares  with  the 
wine  of  the  citrate  of  iron  in  this  disease,  the  small  amount  of 
alcohol  present  being  of  distinct  value.  Absolute  rest  in  bed  is  of 
course  essential.  Persistent  or  severe  headache  is  best  treated  by 
an  ice  cap.  However,  some  children  are  so  restless  that  this  is  an 
almost  impossible  method  and,  in  such  instances,  the  administration 
of  small  doses  of  acetphenetidin  will  bring  relief  and  without  danger 
to  the  heart  unless  its  use  is  continued  over  a  long  period.  For  the 
restlessness  and  possible  delirium,  tepid  baths  of  from  five  to  ten 
minutes'  duration  are  of  value  and  may  be  repeated  every  three  or 
four  hours  if  required.  Free  water  drinking,  regulation  of  the 
bowel  function,  and  strict  attention  to  the  digestion  are  essentials 
in  the  general  treatment.  General  principles  are  applicable  to  the 
complications  which  occur. 


CHAPTER  XXX 

TETANUS 

Etiology:  Bacillus  Tetani. — There  have  been  but  few  more  spec- 
tacular advances  made  in  the  study  and  the  understanding  of  a 
disease  within  the  last  two  decades  than  have  obtained  in  tetanus, 
or,  as  it  is  commonly  called,  lockjaw. 

While  in  remote  times  the  symptomatology  was  recognized  and 
the  relation  of  the  disease  to  wounds  was  clearly  noted,  yet  it  was 
not  until  quite  recent  years  that  the  bacteriologic,  chemical,  etio- 
logical,  and  anatomico-physiological  features  were  given  proper 
interpretation. 

It  was  in  1884  that  the  true  cause  of  tetanus  was  discovered  by 
Nicolaier  and  through  the  influences  of  that  discovery  we  came 
rapidly  to  have  a  clear  appreciation  of  this  dread  disease. 

Following  Nicolaier,  other  investigators  soon  proved  that  this 
specific  bacillus  was  present  in  large  numbers  in  garden  earth,  dust, 
and  wherever  these  were  carried,  but  that  its  occurrence  in  nature 
was  far  from  being  uniform.  Although  much  more  abundant  in 


CLINICAL    FORMS  215 

some  soils  than  in  others,  the  tetanus  bacilli  are  very  common.  Yet, 
in  spite  of  this  fact  and  the  opportunity  which  is  offered  by  the 
body  for  its  entrance  (because  the  minutest  wound  is  sufficient  for 
infection),  the  total  number  of  cases  is  quite  small.  The  reason 
for  this  may  be  found  in  the  biologico-chemical  properties  of  the 
bacillus. 

The  bacillus  only  grows  anaerobically ;  but  it  is  capable  when 
introduced  into  a  wound  of  producing  certain  powerful  poisons 
which  when  absorbed  into  the  system  produce  characteristic  and 
usually  fatal  spasms. 

The  bacillus  has  this  peculiarity:  it  remains  quite  strictly  con- 
fined to  the  site  of  its  introduction  and  has  a  rather  short  life  in 
the  wound  or  point  of  entrance.  But  we  have  learned  that  the 
bacillus  alone  does  not  produce  the  severe  phenomena  which  are  so 
commonly  fatal  to  life,  but  that  these  manifestations  are  due  to 
products  of  metabolism  which  are  traceable  to  the  influence  of 
the  bacillus.  These  toxins  are  developed  at  the  point  of  entrance 
of  the  bacillus  and  by  way  of  the  nerves  advance  toward  the  cord 
and  medulla.  And  it  has  been  proven  that,  although,  the  tetanus 
bacillus  only  lives  at  the  point  of  entrance,  the  toxins  produced 
exhibit  an  entirely  different  characteristic  and  are  taken  into  the 
system  with  extraordinary  rapidity.  Thus  we  find  that  it  is  these 
toxins  which  are  responsible  for  the  clinical  phenomena.  And 
although  there  were  many  theories  advanced  in  the  past  to  explain 
the  occurrence  of  the  clinical  manifestations,  these  were  rather  un- 
satisfactory until  after  much  labor  it  has  been  shown  that  the 
tetanus  toxin  has  a  special  affinity  for  the  substance  of  the  central 
nervous  system.  It  is  not  necessary  to  delay  for  the  final  settle- 
ment of  all  of  the  problems  which  are  still  unsettled  in  regard  to 
the  nature  and  extent  of  this  toxin  affinity,  but  the  surgeon  may 
safely  accept  it  as  a  fact  that  this  affinity  of  the  central  nervous 
system  and  the  toxin  is  not  only  present  but  is  very  marked. 

Clinical  Forms. — Although  there  is  but  one  recognizable  cause 
of  this  disease,  yet  it  is  advisable  for  clinical  purposes  to  recognize 
the  two  forms  of  the  disease  in  childhood.  Tetanus  neonatorum  is 
the  result  of  infection  through  the  umbilical  cord;  tetanus  trau- 


216  TETANUS 

matica  occurs  as  in  the  adult  through  the  influence  of  a  general 
injury  of  more  or  less  severity,  or  through  any  loss  of  continuity 
of  the  skin.  The  symptom-complex  of  the  two  forms  is  so  similar 
that  one  description  will  answer  for  both.  The  only  differences  are 
those  which  are  attributable  to  the  influence  which  the  age  of  the 
patient  has  upon  any  disease. 

Facial  tetanus  is  a  form  of  the  disease  which  is  so  pronounced 
in  certain  particulars  that  it  needs  special  mention.  Its  main 
characteristic  is  that  we  are  not  dealing  with  spasms  of  distinct 
groups  of  muscles  only,  but  along  with  them,  or  preceding  their 
occurrence,  there  is  a  paralysis  of  the  facial  nerve.  This  type  most 
frequently  follows  injuries  to  the  head. 

Chronic  tetanus  is  simply  a  modified  type  of  the  disease  with 
a  longer  period  of  incubation,  a  much  lessened  severity  of  all  the 
symptoms,  and  a  longer  course,  so  that  the  child  may  be  afflicted 
for  one  or  two  months  and  eventually  recover,  or,  as  is  more  often 
the  case,  die  of  the  exhaustion  caused  by  the  disease. 

Symptomatology  and  Diagnosis. — The  most  prominent  symptoms 
are  those  relating  to  the  motor  sphere;  there  is  hardly  a  large 
muscle  group  in  the  body  which  escapes,  although  primarily  and 
most  severely  the  musculature  of  the  head  and  neck  is  affected. 
The  usual  history  is  that  some  days  after  an  injury  (which  may 
not  have  been  noticed  at  the  time  or  thought  of  since  its  infliction) 
there  occurs  an  indefinite  stiffness  of  the  musculature  of  the  neck 
and  jaw.  In  the  infant  the  result  of  this  stiffness  is  an  inability 
to  nurse,  with  its  consequent  train  of  other  symptoms.  This  inabil- 
ity to  nurse  is  almost  invariably  the  first  thing  noted  by  the  mother, 
but  it  is  usually  reported  as  an  effort  upon^the  part  of  the  infant 
to  take  the  nipple  and  accompanied  by  severe  crying  at  the  attempt. 
This  is  due  to  the  spasm  of  the  masseters.  The  stiffness  which  was 
first  noted  rapidly  increases  until  the  jaws  are  set  and  there  is  great 
difficulty  in  even  partially  opening  them.  The  musculature  of  the 
neck  becomes  board-like  in  its  tension,  and  the  head  may  be  drawn 
forcibly  backward.  The  face  is  set  and  the  eyes  are  usually  motion- 
less, the  ala3  nasi  widely  dilated,  and  the  mouth  increased  in 
breadth  and  drawn  downward.  There  may  be  added  to  this  a 


SYMPTOMATOLOGY    AND    DIAGNOSIS  217 

peculiar  facial  grimace  which  is  not  unlike  a  painful  attempt  to 
smile.  This  latter  is  often  present  very  early  and  may  be  the  first 
symptom  noted.  So  severe  may  these  spasms'  become  that  the 
muscle  may  be  ruptured. 

The  musculature  of  the  back  and  the  abdomen  is  next  involved, 
and,  when  this  occurs,  the  position  of  the  whole  body  may  be  either 
one  of  three — opisthotonos,  emprothotonos,  or  pleurothotonos.  As 
a  rule  the  upper  extremity  is  not  involved.  When  the  disease  pro- 
gresses, the  legs,  especially  at  the  knee  joint,  become  affected, 
but  the  feet  and  the  toes  are  usually  spared.  When  the  spasm 
becomes  so  general  that  it  affects  the  musculature  of  the  internal 
organs,  the  termination  is  usually  and  fortunately  rapid.  The  dia- 
phragm is  generally  markedly  involved  in  the  spasm.  The  rapidity 
with  which  this  diaphragmatic  spasm  occurs  at  any  stage  of  the 
disease  adds  an  early  and  grave  danger  of  suffocation. 

When  well  developed,  the  slightest  movement  is  sufficient  to 
bring  on  an  exaggeration  of  the  spasm  of  the  already  tense  and 
board-like  muscles.  The  nerves  of  sight  and  of  hearing  are  exceed- 
ingly and  painfully  sensitive.  Even  the  entrance  of  some  person 
into  the  room,  the  sudden  admission  of  sunlight,  noise,  or  even  sud- 
den draft,  may  bring  on  spasm  and  so  make  the  suffering  of 
the  child  most  excruciating.  Almost  without  variation  the  spasms 
are  tonic,  only  in  rare  instances  being  clonic.  This  recurrence 
of  spasmodic  seizures  leads  one  to  believe  that  there  are  periods 
of  complete  relaxation,  but  this  is  not  so.  There  are  definite  periods 
during  which  there  are  partial  relaxation  and  apparent  rest,  but  it  is 
characteristic  of  the  disease  that,  once  a  muscle  group  is  affected, 
there  is  continuance  of  the  spasm  without  complete  relaxation  at 
any  time. 

Cerebral  symptoms  are  not  very  apt  to  develop  until  near  to  the 
time  of  death,  when  one  may  encounter  delirium,  but  .unfortunately 
in  most  of  the  cases  the  mind  remains  unusually  clear.  Perspira- 
tion is  usually  excessive  and  the  tears  flow  freely  and  in  great 
abundance. 

The  temperature  is  generally  very  high  during  the  height  of 
the  attack  and  just  before  a  fatal  termination  may  rise  still  higher, 


218  TETANUS 

reaching  in  some  instances  110°  to  114°  F.  For  one  or  two  hours 
after  death  occurs  the  temperature  may  still  remain  high. 

With  the  symptoms  well  developed  there  is  but  little  chance  of 
an  error  in  the  recognition  of  the  disease.  But  not  all  cases  are 
typical  in  their  onset  and  development,  and  under  such  circum- 
stances an  error  in  diagnosis  is  not  uncommon  during  the  develop- 
mental stage. 

A  contracture  of  the  musculature  of  the  jaw  may  be  present  in 
a  more  or  less  marked  degree  in  several  conditions  affecting  the 
jaw  itself  or  the  oral  cavity.  Some  of  these  conditions  might  make 
the  diagnosis  difficult  at  first  and  they  must  be  differentiated.  The 
most  common  sources  of  error  are  an  abscess  situated  close  to  the 
masseter,  facial  neuralgia  of  a  severe  type  (particularly  such  as 
may  follow  the  infectious  disease),  hysteria,  meningitis,  and  more 
rarely  complications  of  dentition  and  follicular  tonsillitis. 

It  is  not  difficult  in  the  child  to  determine  whether  or  not  local 
conditions  are  directly  responsible  for  a  seeming  trismus,  and  with 
such  a  distinction  there  is  usually  a  clearing  up  of  all  doubt  as  to 
the  occurrence  of  tetanus.  An  examination  of  the  oral  cavity  under 
any  of  the  above-named  conditions  might  meet  with  considerable 
resistance,  but  this  would  never  be  so  marked  that  it  could  not  be 
overcome  by  a  little  patience.  One  distinctive  feature  would  be 
that,  with  a  true  trismus  due  to  tetanus,  the  attempt  to  overcome  it 
would  result  in  an  exaggeration  of  the  spasm. 

Of  the  general  conditions  which  might  lead  to  an  error  in  diag- 
nosis, we  have  three — meningitis,  hydrophobia  and  strychnin 
poisoning. 

In  the  first  two  of  these  trismus  is  not  a  prominent  feature  and 
may  be  entirely  absent.  The  cerebral  symptoms  of  meningitis  ought 
to  serve  clearly  to  distinguish  it  from  tetanus,  for  in  meningitis 
the  mind  is  not  clear  as  it  is  in  tetanus,  the  cerebral  symptoms  are 
progressive  and  persist  throughout  the  course  of  the  disease,  while 
in  tetanus,  if  present  at  all,  it  is  not  until  the  end  is  near. 

The  history  and  the  characteristic  features  of  hydrophobia  are 
always  sufficiently  marked,  so  that  none  but  the  most  superficial 
examination  would  fail  to  reveal  them. 


PROGNOSIS  219 

In  poisoning  by  strychnin  there  may  or  may  not  be  a  history 
of  the  ingestion  of  the  drug,  so  that  reliance  must  more  often  be 
placed  upon  other  factors.  It  is  particularly  true  of  strychnin 
poisoning  .spasms  that  they  are  most  prominent  in  the  extremities, 
and  this  characteristic  occurs  early.  When  trismus  occurs  at  all 
it  does  so  late.  The  reverse  is  true  of  tetanus;  trismus  is  the  earliest 
symptom  noted  in  nearly  every  case,  and  spasms  of  the  extremities 
are  late  in  occurrence  (the  arms  being  rarely  affected). 

The  contracture  of  the  muscle  in  tetanus  never  completely  sub- 
sides; it  does  have  periods  in  which  there  is  partial  relaxation,  but 
this  is  never  complete.  In  poisoning  by  strychnin  there  are  definite 
periods  of  complete  relaxation.  There  is  a  real  difficulty  offered 
when  we  attempt  to  determine  just  how  many  days  elapse  between 
the  infection  and  the  first  appearance  of  symptoms.  Children  are 
so  commonly  the  subjects  of  injury  that  many  times  the  occurrence 
of  such  is  quickly  forgotten,  so  that  as  an  aid  this  fact  is  often 
valueless. 

It  can  be  readily  seen  that  animal  experimentation  does  not 
help  us  in  this  difficulty  to  any  considerable  extent  because  each 
species  has  a  different  susceptibility  to  the  infection  and  in  the  ex- 
periments the  toxins  are  used. 

Rose  has  carefully  observed  many  cases  in  human  beings,  and 
his  opinion  in  this  particular  should  be  given  considerable  weight. 
He  believes  that  symptoms  arise  during  the  second  week  after  the 
injury  in  about  one-half  of  the  cases  and  that  in  a  third  of  the 
cases  they  show  during  the  third  week.  There  are  still  others  who 
claim  a  much  longer  period  of  latency. 

Prognosis. — The  prognosis  is  quite  intimately  connected  with  the 
period  of  incubation,  for  it  is  a  well-recognized  fact  that  the  more 
rapidly  the  symptoms  develop  after  the  injury  the  more  unfavor- 
able the  prognosis.  But  even  eliminating  those  cases  in  which  the 
period  of  incubation  is  short  and  the  chances  of  recovery  almost  nil, 
the  prognosis  is  far  from  hopeful,  for  about  one-half  of  the  cases 
which  are  developed  late  terminate  unfavorably.  Before  it  was 
possible  to  use  the  antitoxin  for  this  disease  these  figures  were 
higher.  Naturally  the  age  of  the  patient  markedly  influences  the 


220  TETANUS 

prognosis ;  the  younger  the  child  the  less  favorable  the  results. 
There  are  individual  features  of  the  disease  which  are  guides  to 
the  prognosis: 

(a)  A  temperature  of  103°   F.   or  over    (except  in  a  rachitic 
child)   at  the  height  of  the  disease  is  unfavorable. 

(b)  Complete  trismus,  by  its  interference  with  the   nutrition, 
is  an  unfavoring  factor. 

(c)  Involvement  of  the  musculature  of  the  respiratory  tract  or 
of  the  muscles  of  deglutition  is  an  ill  omen. 

(d)  Frequent  or  continued  tetanic  attacks  are  indicative  of  a 
fatal  ending. 

While  it  is  readily  seen  that  any  one  of  these  symptoms  may 
prove  to  be  the  fatal  one  if  they  be  intense  enough,  yet  a  combina- 
tion of  a  lessened  degree  or  two  or  more  of  them  should  be  regarded 
with  great  alarm. 

Tetanus  may  be  regarded  as  the  most  uniformly  fatal  disease 
with  which  the  surgeon  deals,  death  occurring  usually  within  a  very 
few  days  after  the  onset.  And  even  after  the  disease  seems  to  have 
done  its  worst  and  the  symptoms  are  all  improving,  it  is  no  uncom- 
mon experience  to  have  a  sudden  onset  of  some  one  of  the  pre- 
viously mentioned  symptoms  with  early  death.  Therefore  a  most 
guarded  prognosis  must  be  made  up  until  the  time  of  complete 
recovery. 

Treatment. — The  treatment  involves   four  main  propositions: 

(1)  The  treatment  of  the  injury  or  wound. 

(2)  The  specific  serum  therapy. 

(3)  General  medical  treatment. 

(4)  Dietetic  care  and  general  nursing. 

TREATMENT  OF  THE  WOUND. — The  treatment  of  the  wound  de- 
mands a  clear  appreciation  of  what  is  to  be  accomplished  and  the 
most  energetic  measures  to  bring  about  the  result. 

The  toxin  developed  by  the  bacillus  does  not  act  in  the  wound 
itself  but  is  carried  with  great  rapidity  by  the  lymph  channels  and 
the  blood  to  the  central  nervous  system.  Thus  the  treatment  of  the 
wound  depends  somewhat  upon  the  time  at  which  the  child  is  seen 
and  resolves  itself  into  two  methods:  prophylactic  and  direct. 


TREATMENT  221 

The  prophylactic  method  need  not  be  enlarged  upon  because  the 
surgeon  of  to-day,  recognizing  the  absolute  necessity  of  asepsis, 
cleanses  every  wound  no  matter  how  slight  before  he  feels  secure 
in  any  further  surgical  procedure.  But  when  the  wound  is  con- 
taminated with  earth,  it  is  necessary  to  use  the  most  powerful  anti- 
septics or  the  cautery  to  destroy  the  bacillus.  Nothing  short  of 
the  most-  energetic  measures  will  suffice,  because  the  bacillus  is 
exceedingly  resistant  to  external  influences,  and,  on  the  other  hand, 
may  remain  in  the  wound,  constantly  producing  fresh  toxins. 

The  direct  treatment  is  that  which  is  taken  after  the  patient 
has  exhibited  the  earliest  signs  of  the  disease  and  involves  a  most 
thorough  search  for  all  possible  points  of  entrance.  It  is  not  suffi- 
cient to  give  attention  to  one  wound,  no  matter  how  serious  it  may 
seem,  but  every  wound  (the  slightest  as  well  as  the  severest)  should 
receive  examination  and  care. 

While  it  is  impossible  to  foretell  by  the  first  symptoms  just 
what  amount  of  toxemia  is  present,  yet  the  complete  direct  treat- 
ment of  all  wounds  offers  a  considerable  amount  of  protection  to 
the  child. 

The  treatment  involves  the  thorough  use  of  such  methods  as 
have  been  advised  in  the  prophylactic  treatment  of  the  wound,  and, 
in  addition  to  these,  deep  incisions  into  the  wound,  or  in  some 
instances  complete  excision  of  the  wound.  Extirpation"  is  as  far  as 
the  surgeon  need  go;  amputation  of  a  limb  is  never  necessary. 

TETANUS  ANTITOXIN. — The  value  of  this  agent  and  its  capabil- 
ities as  a  protective  are  settled  beyond  any  reasonable  doubt.  But 
to  get  the  best  obtainable  results  from  its  use,  the  surgeon  must 
appreciate  some  of  the  peculiarities  of  the  agent.  And,  first,  it  has 
been  experimentally  proven  that  absorption  is  very  slow,  so  that 
the  maximum  amount  is  not  found  in  the  circulation  until  twenty- 
four  hours  or  more  have  elapsed  since  its  injection. 

Secondly:  Examinations  of  the  secretions  and  excretions  show 
that  most  of  the  antitoxin  is  eliminated  unchanged. 

Thirdly:  The  antitoxin  does  not  destroy  the  toxin,  but  simply 
through  some  unaccountable  chemical  influence  renders  it  inert. 

Fourth   (and  most  significant  of  all)  :  The  nervous  system,  as 


222  TETANUS 

represented  by  the  nerve  tissue,  does  not  in  any  manner  take  up 
the  antitoxin. 

To  return  to  the  tetanus  bacillus,  it  generates  its  toxins  so 
rapidly,  the  toxin  is  so  virulent  (the  minutest  quantity  being  suf- 
ficient to  bring  about  fatal  results),  that  no  time  can  be  lost  in 
administering  the  antitoxin.  The  behavior  of  the  antitoxin  experi- 
mentally indicates  the  best  methods  of  its  use.  This  must  be  im- 
mediate because  of  the  slow  absorption  of  the  agent  and  the  rapid 
action  of  the  tetanus  bacillus  and  therefore  it  may  be  administered 
intravenously  and  about  the  tissues  in  the  affected  areas. 

However,  for  the  most  prompt  and  certain  action,  there  is  no 
method  which  is  superior  to  the  intraspinal  injection.  In  this 
operation,  spinal  puncture  is  performed  as  usual  and  from  five  to 
ten  c.  c.  of  the  spinal  fluid  allowed  to  escape.  Then  an  equal 
amount  of  the  antitoxin  is  injected  directly  but  slowly  into  the 
canal.  When  later  injections  are  required,  the  intravenous  method 
or  the  much  slower  subcutaneous  method  may  be  serviceable. 

Rogers  advocates  a  plan  somewhat  like  this :  10  to  20  c.  c.  are 
injected  into  the  tissues  about  the  affected  area;  10  to  20  c.  c.  intra- 
venously; 5  to  20  minims  into  the  nerves  of  the  axillary  plexus  if 
the  wound  is  of  the  upper  extremity;  in  the  crural,  sciatic,  and 
obturator  nerves  if  in  the  lower.  Of  course,  such  dosage  is  his 
method  for  adults. 

For  children  the  dose  must  be  modified  according  to  the  stage 
of  the  disease,  the  lateness  of  the  appearance  of  symptoms  after  the 
injury,  and  the  age  of  the  child.  But  for  an  average  case  and  an 
average  child  the  dosage  would  be:  for  one  year,  1,000  to  3,000 
units;  for  five  years,  3,000  to  5,000  units;  ten  years,  8,000  to 
12,000  units,  and  the  frequency  of  these  doses  should  be  every 
four,  six,  or  eight  hours  (never  longer  than  eight  hours). 

For  immunization,  an  average  dose  of  from  400  to  800  units 
should  be  given. 

GENERAL  MEDICAL  TREATMENT. — The  general  medical  treat- 
ment brings  up  at  once  the  consideration  of  the  use  of  opium  or 
its  derivatives.  Its  use  is  at  once  attended  with  good  results,  for 
it  diminishes  the  intensity  of  the  spasms  and  even  seems  to  have 


TREATMENT  223 

some  influence  in  prolonging  the  intervals  between  them.  Its  action 
is  favorable  on  the  insomnia  which  is  so  characteristic  of  tetanus. 
Preference  naturally  should  be  given  to  morphin  because  of  its 
known  reliability  and  more  constant  uniformity  of  action.  Per- 
sonally, we  are  adverse  to  the  use  of  morphin  by  the  mouth  or 
by  suppository,  for  more  certain  results  are  secured  by  the  hypo- 
dermic administration. 

Chloral  holds  place  as  a  close  second  to  morphin,  but  its  lis- 
agreeable  taste  easily  excites  spasm  of  the  muscles  of  deglutition 
in  children  and  therefore  it  is  best  given  per  rectum  in  milk. 

A  combination  of  these  two  drugs,  carefully  adjusted  to  the 
individual  need,  practically  meets  every  indication  for  drug  treat- 
ment. But  to  secure  the  proper  results  the  individual  need  must 
be  studied  and  the  dosage  of  the  drugs  made  large  enough  to  meet 
it.  Subcutaneous  injections  of  sulphate  of  magnesia  have  not 
proved  satisfactory  in  our  hands,  on  account  of  the  sudden  respira- 
tory paralysis. 

Many  other  drugs  have  been  recommended  from  time  to  time, 
notably  large  doses  of  the  bromids  and  the  salicylates,  but  their 
action  is  weak  and  therefore  doubtful.  Before  leaving  this  subject 
we  must  mention  the  advantage  gained  by  narcosis.  The  adminis- 
tration of  an  anesthetic  by  a  skilled  hand  will  accomplish  a  com- 
plete subsidence  of  the  trismus  and  thereby  allow  the  introduction 
of  a  stomach  tube  and  the  administration  of  nourishment,  or  may 
render  it  safe  for  the  surgeon  to  undertake  some  surgical  pro- 
cedure which  would  be  impossible  without  narcosis.  But  the 
dangers  of  such  a  procedure  as  anesthesia  must  be  recognized,  and 
therefore  the  administration  must  be  in  the  most  skilled  hands  to 
prevent  the  rapid  termination  of  the  life  of  the  child  by  suffoca- 
tion. The  choice  of  the  anesthetic  is  determined  in  the  same  man- 
ner as  in  any  child  who  is  to  be  the  subject  of  surgical  intervention 
(see  page  61),  and  in  addition  is  influenced  by  the  object  sought. 
If  this  is  merely  the  control  of  the  spasms,  chloroform  is  the  choice 
on  account  of  its  rapid  action. 

DIET  AND  GENERAL  NURSING. — The  dietetic  care  and  general 
nursing  are  at  once  very  difficult  because  the  general  standard  of 


224  TETANUS 

what  constitutes  good  nursing  and  feeding  cannot  be  carried  on  in 
this  disease.  The  nutrition  of  the  child  is  particularly  difficult  to 
maintain,  so  that  it  is  our  common  experience  that  children  die 
from  sheer  exhaustion  long  before  the  disease  has  advanced  to  the 
danger  point.  The  trismus  may  be  so  marked  that  it  is  impossible 
to  force  the  jaws  open  sufficiently  to  give  even  the  minutest  quan- 
tity of  food.  There  are  three  methods  by  which  we  may  feed  the 
child :  by  rectum,  subcutaneously,  and  by  the  stomach  tube  after 
narcosis. 

Rectal  feeding  is  accomplished  as.  in  any  other  condition  (see 
page  104),  and  is  the  least  desirable  of  the  three  methods  because 
the  manipulation  necessary  usually  brings  about  spasms,  which  are 
exhausting  and  at  once  interfere  with  the  continuance  of  the 
method. 

The  subcutaneous  method  is  more  serviceable  than  the  rectal, 
but  there  are  certain  precautions  that  must  be  observed.  While  the 
preparation  of  the  nutriment  is  done  with  the  careful  attention  to 
detail  which  is  advisable  under  all  other  conditions  (consideration 
of  these  points  would  unnecessarily  enlarge  this  section,  therefore 
the  reader  is  referred  to  the  books  upon  Dietetics),  in  addition  to 
this  the  preparation  must  be  done  away  from  the  room  of  the 
patient  and  the  disinfection  of  the  skin  be  most  thorough.  Two  hun- 
dred c.  c.  of  olive  oil  given  in  this  manner  represents  nearly  2,000 
calories  and  the  disturbance  to  the  child  in  its  administration  is 
slight.  After  the  withdrawal  of  the  needle,  which  must  be  small, 
the  puncture  should  be  covered  with  collodion. 

Whenever  the  trismus  allows  it,  food  should  be  given  by  the 
mouth  and  a  selection  made  of  such  nourishment  as  contains  in 
the  least  bulk  the  greatest  food  value.  Every  precaution  should 
be  taken  to  have  the  vessels  containing  the  food  of  such  a  substance 
as  will  not  be  broken  if  a  spasm  comes  on  while  the  child  is  being 
fed.  One  of  the  most  satisfactory  methods  is  to  allow  the  child 
to  use  a  common  nursing  nipple,  for  in  this  way  the  food  is  taken 
at  the  rate  required  and  there  is  no  danger  of  breakage.  In  giving 
liquid  nourishment  the  attention  of  the  child  should  bs  attracted 
to  the  fact  that  he  is  taking  such,  because  without  this  there  is 


TREATMENT  225 

danger  of  regurgitation  and  through  that  of  an  aspiration  pneu- 
monia. The  most  serviceable  foods  are  the  dry  beef  peptonoids, 
strong  beef  tea  with  raw  egg,  cream,  cocoa  or  chocolate,  beef  juice, 
and  dextrinized  cereals  which  have  been  concentrated  by  further 
heating.  Sugar  of  milk  should  be  used  freely  in  the  food,  not 
because  of  its  sweetening  effect  but  as  a  carbohydrate. 

Just  as  soon  as  the  condition  of  the  child  warrants  it,  the  food 
should  be  increased  in  variety  but  with  the  precaution  that  the 
dangers  from  aspiration  be  avoided.  Briefly  stated,  the  nutrition 
should  conform  to  the  stage  of  the  disease  but  at  all  times  should 
be  as  concentrated  and  as  highly  nutritious  as  possible.  Feeding 
by  the  stomach  tube  after  narcosis  is  not  without  danger  as  has 
already  been  suggested  (see  page  223),  but  it  may  become  neces- 
sary or  even  expedient  to  undertake  this  method  once  in  twenty- 
four  or  forty-eight  hours  in  conjunction  with  one  of  the  other 
methods  of  feeding.  The  disadvantages  are  that  the  amount  of 
nutrient  given  this  way  must  be  limited  by  the  capacity  of  the 
stomach  and  there  is  constantly  the  danger  of  an  aspiration  pneu- 
monia when  the  tube  is  removed. 

Actual  nursing  as  it  is  practiced  in  other  conditions  is  an  im- 
possibility in  the  case  of  tetanus  because  motion,  noise,  and  excite- 
ment of  any  kind  must  be  limited  in  the  sick-room.  The  failure  to 
control  these  features  will  result  in  the  occurrence  of  repeated 
spasm.  The  room  selected  to  confine  the  child  should  be  one  as  far 
removed  from  the  street  and  from  the  necessary  noise  of  the  house- 
hold as  possible.  Further  protection  is  offered  by  the  hanging  of 
heavy  curtains  at  the  doors  and  the  wearing  of  soft  slippers  by  the 
attendants.  The  room  should  be  somewhat  darkened  but  well 
ventilated,  and  if  a  change  is  necessary  in  either  of  these,  that  is, 
if  more  light  is  to  be  admitted  or  thorough  airing  done,  the  process 
should  be  gradual  because  even  these  slight  sudden  changes  often 
bring  about  a  spasm. 

The  bed  should  be  broad  enough  to  prevent  falling  out  during  a 
spasm  and  if  possible  the  mattress  should  be  of  water  or  feathers 
to  limit  injury.  The  upper  board  of  the  bed  must  be  protected  so 
as  to  prevent  injury  during  an  extensor  spasm,  Conservatism  in 


226  SEPTIC  DISEASES 

the  nursing  is  wisdom  and  the  whole  attitude  of  the  nurse  should 
be  one  of  watchful  care  rather  than  strict  attention  to  the  niceties 
of  the  sick-room.  The  best  interests  of  the  child  demand  not  only 
that  the  absolutely  necessary  attentions  be  given  but  that  he  be  pro- 
tected from  possible  injury  during  the  spasms. 

There  can  be  little  question  but  that  full  baths  have  a  decided 
and  favorable  influence  upon  the  spasms  of  tetanus,  but  whatever 
good  is  accomplished  by  them  is  probably  more  than  counterbal- 
anced by  the  necessary  manipulations  of  the  child  in  the  accomplish- 
ment. It  is  only  under  the  most  favorable  circumstances  that  bath- 
ing can  be  safely  indulged  in,  and  then  the  bath  should  be  a  warm 
one  no  matter  whether  fever  is  present  or  not.  The  reaction  from 
a  cool  bath  or  even  cool  sponging,  which  is  so  favorable  in  other 
conditions  in  children,  is  decidedly  unfavorable  in  tetanus  and  tends 
to  increase  spasms. 

CHAPTEK  XXXI 

SEPTIC    DISEASES 

SEPTIC  DISEASES  IN  GENERAL 

Septic  intoxication  indicates  that  the  symptomatology  is  de- 
pendent upon  absorption  of  the  toxic  products  of  pus-producing 
organisms  from  a  focus  of  suppuration  and  in  this  it  is  quite  dif- 
ferent from  septicemia,  which  is  a  form  of  infection  in  which  the 
living  pus  organisms  are  existent  in  the  blood  and  multiply  there. 
And,  further,  it  is  distinguished  from  pyemia,  which  is  that  form 
of  poisoning  in  which  the  organisms,  having  entered  the  blood,  are 
carried  to  distant  parts  and  by  lodgment  there  form  new  foci  of 
suppuration. 

This  division  is  not  simply  arbitrary  but  is  based  upon  clinical 
characteristics  and  helps  materially  in  the  understanding  of  the 
correct  surgical  interference  to  establish. 

Blood  cultures  are  of  value  in  the  severer  forms  of  infection 
because  it  is  practically  always  possible  to  isolate  one  or  the  other 


SEPTIC    INTOXICATION  227 

of  the  various  forms  of  pyogenic  cocci  in  the  blood  and  this  having 
been  established  it  may  be  feasible  to  institute  appropriate  sera  or 
vaccine  treatment. 

Not  only  this,  but  the  recognition  of  the  particular  organism 
adds  considerable  value  to  the  statements  as  to  prognosis.  And 
the  most  definite  data  that  can  be  obtained  upon  which  to  base 
the  prognosis  is  of  considerable  value  in  aiding  the  surgeon  in  his 
determination  as  to  just  what  surgical  measures  to  pursue. 


SEPTIC    INTOXICATION 

Septic  intoxication  may  exist  in  almost  any  degree,  as  for 
instance  in  those  cases  in  which  there  are  only  the  almost  unappre- 
ciated symptoms  of  mild  malaise  and  an  elevation  of  the  tempera- 
ture of  considerably  less  than  one  degree  to  those  fulminating  cases 
which  may  be  fatal  within  a  few  hours  after  their  onset.  This  is 
so  because  the  condition  is  present  to  some  extent  whenever  an  acute 
infection  by  the  pus-producing  organisms  exists  in  the  body. 

Symptoms. — While  it  might  be  stated  generally  that  the  sympto- 
matology is  influenced  directly  by  the  virulence  of  the  bacteria  and 
the  amount  of  the  toxins  absorbed  plus  certain  local  conditions,  yet 
there  are  many  other  modifying  factors  which  will  be  mentioned 
later. 

Chief  among  the  local  modifying  conditions  is  that  of  tension, 
for  if  pus  is  confined  in  unyielding  tissues  it  is  more  certain  to 
cause  important  constitutional  symptoms  than  when  not  under 
pressure.  And  it  is  a  well-established  fact  that  certain  tissues 
are  much  more  absorbent  than  are  others,  and  this  has  a  decided 
influence. 

The  constitutional  symptoms  are  fever,  a  rapid  pulse,  prostra- 
tion, thirst,  malaise,  more  or  less  profuse  sweating,  possibly  chills, 
convulsions,  or  other  symptoms. 

The  fever  is  usually  remittent  or  may  be  intermittent  and  when 
improvement  is  not  taking  place  the  tendency  is  upward  until 
death  takes  place.  The  pulse  is  rapid  in  all  cases,  but  is  full  in 


228  SEPTIC  DISEASES 

the  moderate  infections,  while  it  is  rapid  and  weak  in  the  severer 
ones.  There  is  usually  a  well-marked  preservation  of  the  tempera- 
ture rise  as  related  to  the  pulse  rate.  If,  on  the  other  hand,  there 
is  low  temperature  with  rapid  pulse  it  indicates  that  there  is  a 
grave  form  of  poisoning.  While  a  high  temperature  and  a  cor- 
responding rapid  pulse  indicate  considerable  severity  of  the  infec- 
tion, their  continuous  correspondence  is  of  itself  a  rather  favorable 
sign. 

The  removal  of  tension  or  the  evacuation  of  the  offending  mate- 
rial by  removing  the  inflammatory  focus  results  in  immediate  re- 
duction in  the  height  of  the  temperature,  although  if  the  surgical 
procedure  undertaken  to  accomplish  this  has  involved  the  lymph 
spaces,  there  may  be  a  temporary  fall  in  the  temperature  followed 
by  an  immediate  rise  and  again  followed  by  a  more  or  less  rapid 
fall  to  normal  or  nearly  so. 

If,  after  appropriate  surgical  interference,  the  symptoms  do  not 
show  an  immediate  improvement  and  recovery  become  established, 
septicemia  is  to  be  suspected,  although  we  must  also  remember  that 
it  is  not  always  possible  to  immediately  establish  adequate  surgical 
relief  either  as  regards  the  relief  of  tension  or  of  evacuation,  and 
in  such  instances  an  immediate  subsidence  of  the  symptoms  cannot 
be  looked  for.  It  is,  therefore,  not  always  possible,  even  with 
surgical  intervention,  to  definitely  establish  the  diagnosis  between 
septic  intoxication  and  septicemia. 

Septic  intoxication  may  result  from  unavoidable  or  unconscious 
errors  in  operative  work.  This  is  generally  evidenced  within  forty- 
eight  hours  by  restlessness  and,  if  the  child  be  old  enough  to  com- 
plain intelligently,  by  a  sense  of  pain  or  discomfort  in  the  wound. 
However,  it  must  be  remembered  that  children,  even  of  a  consider- 
able age,  do  not  complain  because  of  the  fear  of  further  interference 
and,  in  fact,  many  are  led  to  deceive  in  this  matter. 

The  constitutional  symptoms  are  of  more  value  than  any  state- 
ment of  the  child,  and  slight  but  progressive  rise  of  temperature, 
associated  with  thirst,  restlessness,  coated  tongue,  a  flushed  face, 
and  bright  eye,  should  always  arouse  suspicion  and  lead  to  an  im- 
mediate inspection  of  the  wound, 


SEPTICEMIA  229 

Headache  and  a  general  sense  of  discomfort  with  scanty  urine 
and  constipated  bowels  are  later  symptoms. 

It  is  easy  to  attribute  the  early  symptoms  to  some  digestive 
disturbance,  or  to  accept  them  as  due  to  constipation  if  it  exists, 
and  this  is  particularly  so  if  the  statements  of  the  child  are  ac- 
cepted, but  the  only  line  of  safety  is  in  not  accepting  this  lazy 
solution  of  a  symptomatology  which  may  mean  much  to  the  child. 

An  examination  of  the  wound  shows  it  to  be  red,  swollen,  and 
tender  and  there  may  be  minute  areas  of  necrotic  tissue;  or  the 
wound  may  appear  free  from  inflammation  and  it  is  only  by  deep 
pressure  that  tenderness  is  elicited.  Upon  opening  the  wound  pus 
is  evacuated  usually  along  the  lines  of  the  sutures,  and  this  evacua- 
tion and  relief  of  tension  are  followed  by  prompt  subsidence  of  all 
symptoms  and  rapid  healing. 


SEPTICEMIA 

Septicemia  is  that  form  of  blood  poisoning  in  which  the  living 
pus  organisms  exist  in  the  blood  and  multiply  there.  It  is,  there- 
fore, not  to  be  expected  that  the  removal  of  the  local  lesion  will 
result  in  an  arrested  progress  of  the  disease  and  in  this  particular 
it  is  characteristically  different  from  septic  intoxication. 

Symptoms. — The  symptoms  are  not  always  characteristic  but 
usually  beffin  with  some  malaise  and  fever  and  the  child  shows  L 

*>  o 

decided  disinclination  for  its  usual  activities.  In  other  instance? 
there  is  a  more  acute  onset  with  a  decided  chill  or  convulsion  and 
followed  quickly  by  marked  prostration,  headache,  a  typhoidal  state, 
and  a  fluctuating  temperature.  The  pulse  is  rapid  and  weak,  no 
matter  what  the  type  of  onset.  Septic  rashes  are  common  and  may 
be  erythematous,  petechial,  pustular,  or  hemorrhagic. 

Diarrhea  and  splenic  enlargement  are  common.  Septic  endo- 
carditis, pericarditis,  bronchitis,  or  pneumonia  may  occur. 

Increasing  prostration,  profuse  sweating,  uncontrollable  diar- 
rhea, progressively  failing  pulse,  excessive  thirst,  and  exhausting 
restlessness  are  added  as  the  disease  progresses. 


230  SEPTIC  DISEASES 

The  blood  examination  shows  a  marked  leukocytosis  and  by  cul- 
ture the  invading  organism  may  be  isolated. 

Prognosis. — The  prognosis  is  always  grave,  although,  happily, 
we  seldom  encounter  the  disease  during  childhood. 

Treatment. — The  treatment  always  involves  the  adequate  surgical 
treatment  of  the  local  lesion  whenever  that  is  practical,  and  this 
may  require  incision,  drainage,  curetting,  cauterization,  continu- 
ous immersion  or  irrigation,  or  the  Bier  hyperemic  method. 

The  general  treatment  is  most  important  and  should  be  sup- 
portive and  stimulating  plus  all  measures  which  favor  elimination 
through  the  bowels,  kidneys,  and  skin.  Maintenance  of  the  nutri- 
tion is  exceedingly  important  and  the  efforts  which  are  spent  upon 
this  one  factor  alone  often  decide  the  final  outcome  of  the  disease. 

Vaccine  therapy  is  considered  in  another  section,  to  which  the 
reader  is  referred. 

PYEMIA 

Etiology. — Pyemia  is  not  at  all  common  in  children,  and  this 
is  probably  due  to  two  factors: — the  modern  method  of  dealing 
with  wounds,  and  the  liability  of  the  child  to  the  more  extreme 
results  of  infection.  Pyemia  is  that  form  of  infection  in  which 
the  organisms,  having  entered  the  blood,  are  carried  to  distant 
parts  and  there  find  lodgment  and  form  new  foci  of  suppuration. 
The  emboli  have  their  genesis  in  infected  thrombi  formed  in  the 
veins,  the  vessel  being  infected  from  without  by  extension  of  an 
infectious  inflammation  or  the  adherence  to  its  walls  of  bacteria 
circulating  in  the  blood. 

Any  pus-producing  organism  may  cause  pyemia. 

Symptoms. — The  symptoms  are  variable,  on  account  of  the  degree 
of  accompanying  septicemia,  the  location  and  number  of  metastatic 
foci,  and  whether  the  disease  assumes  the  acute  or  chronic  course. 

If  a  child  is  suffering  from  an  infected  wound  or  acute  septic 
inflammation,  and  develops  a  chill  or  convulsion  with  a  sudden  high 
temperature,  followed  by  as  rapid  a  fall  and  profuse  sweating,  it 
should  lead  at  once  to  the  suspicion  of  embolic  metastasis. 


SAPREMIA  231 

Subsequent  chills  or  convulsions  and  elevations  of  the  tempera- 
ture follow  an  irregular  type  and  simulate  malarial  fever. 

Diarrhea,  foul  breath,  anorexia,  coated  tongue,  jaundice,  and 
headache  are  of  common  occurrence.  The  spleen  may  be  enlarged. 
The  mental  condition  may  remain  unchanged,  although  irritability 
and  undue  restlessness  are  the  rule.  Each  new  chill  and  elevation 
of  temperature  leave  the  child  much  worse.  Anemia  and  pros- 
tration are  early  and  marked. 

The  local  changes  are  also  marked: — if  the  wound  is  actively 
suppurating,  with  the  onset  of  pyemia,  the  discharge  is  much 
lessened  and  the  surface  becomes  drier  and  pale,  the  existing  granu- 
lations appearing  anemic  and  possibly  softening  and  disappearing. 

Any  tissue  may  be  invaded  and  new  abscesses  form  from  time 
to  time  and  this  may  occur  insidiously  and  rapidly.  Each  new 
chill  or  convulsion  indicates  fresh  involvement  and  these  should  be 
sought  and  subjected  to  surgical  interference  if  possible. 

Complications. — Complications  are  of  course  common,  as  the 
infection  is  very  liable  to  be  carried  into  important  organs  inac- 
cessible to  surgical  relief.  Thus  the  prognosis  is  always  very  grave. 

Diagnosis. — In  the  diagnosis,  malaria  may  be  excluded  by  blood 
examination,  which  would  show  no  presence  of  the  plasmodium  and 
absence  also  of  leukocytosis. 

Acute  miliary  tuberculosis  and  typhoid  fever  and  that  rarer 
disease,  malignant  endocarditis,  must  be  excluded. 

Treatment. — The  treatment  is  upon  the  same  principles  as  that 
of  septicemia  plus  the  opening,  the  cleansing,  or  the  extirpation  of 
the  infected  vessels  in  the  neighborhood  of  the  wound,  or  it  may 
be  advisable  to  ligate  a  vessel.  The  metastatic  abscesses  must  be 
surgically  treated  whenever  they  are  found  and  can  be  reached. 


SAPREMIA 

Etiology. — Sapremia,  or  putrid  intoxication,  is  the  condition 
which  is  caused  by  the  absorption  into  the  system  of  the  products 
of  the  bacteria  of  putrefaction.  A  pure  sapremia  rarely,  if  ever, 


SEPTIC  DISEASES 

exists  alone,  there  being  in  practically  every  instance  the  toxemia 
of  other  pus-producing  organisms.  In  children  the  consequences 
of  the  disease  are  of  far  more  importance  than  in  adults,  because 
with  them  there  are  usually  the  most  extreme  results  as  far  as  the 
ravages  of  the  infection  are  concerned. 

Symptoms  and  Diagnosis. — The  symptoms  are  those  of  a  sudden 
intoxication  and  usually  are  ushered  in  with  a  chill  or  a  convulsion 
and  a  rapid  rise  in  the  temperature.  In  some  instances  the  rise  in  the 
temperature  is  the  first  thing  noted  and  for  several  hours  may  remain 
the  only  symptom.  It  is  only  in  rare  instances  that  there  are  pro- 
dromal symptoms  of  malaise,  anorexia,  headache,  and  prostration. 
The  temperature  usually  rises  rapidly  to  103°  or  even  106°  F.  and 
is  associated  with  a  rapid  pulse. 

After  these  initial  symptoms  the  child  may  be  overwhelmed  by 
the  poison  and  rapidly  become  delirious  or  comatose,  with  a  quickly 
and  persistently  failing  circulation,  so  that  the  body  is  bathed  in 
a  profuse,  cold  perspiration.  Thus  it  may  be  that  the  symptoms  in 
their  severity  resemble  those  of  shock. 

A  more  common  occurrence,  however,  is  for  the  initial  symptoms 
to  be  added  to  by  those  of  marked  prostration,  headache,  vomiting, 
and  extreme  restlessness.  The  failing  circulation  is  always  a  char- 
acteristic, even  in  the  milder  cases. 

The  diagnosis  is  established  as  a  rule  by  surgical  interference,  for 
the  very  nature  of  the  disease  makes  any  unnecessary  delay  dangerous. 
Thus,  if  there  be  a  pure  sapremia,  the  removal  of  the  offending  ma- 
terial will  be  followed  by  immediate  improvement  in  all  of  the  symp- 
toms and  there  is  no  return  of  these  symptoms. 

Having  a  focus  of  dead  material  within  the  body  and  these 
symptoms  added,  we  are  practically  certain  of  the  diagnosis  of  this 
form  of  infection. 

The  wound  itself  may  be  tender  and  painful  and  excrete  a  thin 
but  foul-smelling  discharge. 

Naturally  the  constitutional  symptoms  will  be  influenced  by  the 
size  and  character  of  the  absorbing  surface,  the  amount  of  the  putrid 
material  present,  the  degree  of  pressure  present,  and  the  age  and 
general  nutritional  state  of  the  child. 


PURULENT   INFECTIONS    OP   THE    SKIN  233 

Continuance  of  the  symptoms,  or  their  failure  to  promptly 
respond  to  surgical  interference,  indicates  a  mixed  infection. 

Combinations  of  sapremia  with  septic  infection,  saprophytic, 
and  pyogenic  infection  are  very  common,  and  the  resultant  local 
lesion  and  constitutional  symptomatology  may  be  of  any  possible 
severity.  Thus  we  may  encounter  moist  gangrene  and  like  lesions 
as  examples  of  the  severer  types.  The  less  severe  ones  are  rather 
common  as  the  result  of  injury  with  extensive  laceration  or  con- 
tusion. 

Treatment.' — The  general  treatment  demands  the  judicious  assist- 
ance of  all  of  the  eliminative  forces  in  their  work,  the  regulation  of 
the  diet,  and  appropriate  symptomatic  treatment. 

With  the  prompt  and  adequate  establishment  of  surgical  inter- 
ference, the  prognosis  is  favorable  if  the  wound  is  easily  accessible, 
all  symptoms  usually  subsiding  within  forty-eight  hours. 


PURULENT  INFECTIONS  OF  THE  SKIN  AND   SUB- 
CUTANEOUS  TISSUES 

The  two  factors  of  enfeebled  resistance  to  infection  and  a  tender 
skin  make  serious  affections  of  young  children  possible  through  in- 
fection. Abscess,  furuncle,  or  phlegmon  may  result  as  the  invasion 
of  bacteria  (usually  the  staphylococcus  pyogenes  aureus),  which 
cause,  by  the  action  of  their  virus  or  their  interference  with  the 
nutrition  of  the  parts,  a  necrosis  of  the  tissues  with  the  signs  of 
inflammation  and  the  formation  of  pus.  When  the  tissue  breaks 
down  it  is  usually  eliminated  by  breaking  through  the  skin. 

Naturally  we  find  that  in  those  infants  or  children  in  whom 
the  nutritive  processes  are  disturbed,  or  are  not  up  to  normal,  such 
processes  are  much  more  active  and  add  to  the  already  debilitated 
state. 

These  infections  may  remain  single  or  may  run  together  and 
undermine  a  considerable  area  of  the  skin.  Furuncles  run  prac- 
tically the  same  course  as  in  adults,  except  that  they  appear  in 
large  numbers  and  over  a  long  period  in  malnourished  infants,  par- 


234  SEPTIC  DISEASES 

ticularly  over  the  buttocks,  scalp,  thighs,  and  shoulders.  Any  one 
or  more  of  these  may  become  gangrenous  and  cause  a  general  in- 
fection and  to  that  extent  they  are  serious.  In  evacuating  the  pus 
in  furunculosis,  the  surrounding  skin  should  be  adequately  protected 
by  ointment  or  collodion,  otherwise  the  infection  may  be  spread. 
Squeezing  or  pressing  is  dangerous  because  of  its  liability  to  injure 
the  protective  wall  of  the  cavity  and  thus  change  a  localized  into  a 
generalized  infection.  Every  procedure,  no  matter  how  apparently 
slight  it  may  seem,  should  take  recognition  of  the  possibility  of 
considerable  loss  of  blood  or  the  opening  up  of  new  avenues  of  in- 
fection, both  of  which  children  bear  badly. 

Spontaneous  rupture  seems  to  leave  the  least  scarring,  and, 
therefore,  it  is  advisable  in  most  instances  to  avoid  incision  or  punc- 
ture in  prominent  places.  With  protection  of  the  skin  against 
injury  (which  is  possible  also  through  excessive  sweating,  poorly 
adjusted  clothing,  etc.),  and  reasonable  warmth,  many  of  these  chil- 
dren do  well  without  surgical  interference. 

It  must  be  distinctly  remembered  that  this  type  of  local  infec- 
tion is  a  different  proposition  from  a  similar  condition  in  adults, 
and  while  in  the  latter  free  incisions  would  be  the  proper  procedure, 
the  opposite  is  true  in  childhood.  Klapp's  method  of  drawing  out 
the  pus  by  puncture  and  suction  by  cups  is  a  splendid  one  and  can 
be  done  without  harm  to  the  child. 

Abscesses  are  treated  very  much  in  the  same  manner  as 
furunculosis,  in  that  the  skin  is  protected  and  as  soon  as  fluctuation 
is  detected  an  incision  is  made  and  the  pus  evacuated  (preferably 
by  aspiration).  Packing  may  result  in  necrosis  and  is  unnecessary 
as  the  use  of  a  probe  is  sufficient  to  open  the  incision  again.  Drain- 
age tubes  are  only  necessary  when  pus  is  deep  seated  and  the  mouth 
of  the  wound  persistently  closes. 

Phlegmons  require  similar  treatment  with  such  modifications 
as  the  individual  case  suggests. 

The  general  symptoms  of  all  types  of  these  infections  are  de- 
pendent upon  the  extent,  the  location,  and  the  duration  of  the  pro- 
cess. With  an  increase  of  the  size  of  the  affected  area  there  is  an 
increase  of  general  symptoms. 


BACTEKIAL    VACCINES  235 

Bier's  method  of  producing  hyperemia  is  of  large  service  in  some 
instances  in  which  the  focus  is  situated  upon  a  limb.  Many  of  the 
failures  attributed  to  this  method  have  undoubtedly  come  from  a 
lack  of  appreciation  of  its  general  principles  and  a  consequent  mis- 
application of  the  method.  A  correct  understanding  of  these  is 
so  indispensable  that  it  is  not  within  the  scope  of  this  work  to  go 
into  details  which  are  essential  for  the  successful  use  of  this  method, 
and  therefore  the  reader  is  referred  to  Bier's  own  writings,  or  the 
translations  made  by  Meyer. 

Bier's  method  should  be  used  in  conjunction  with  and  not  apart 
from  other  well-recognized  surgical  procedures. 


CHAPTER  XXXII 

BACTERIAL    VACCINES 

The  theory  of  a  bacterial  vaccine  is  that  when  it  is  injected 
it  has  a  similar  effect  to  that  produced  in  the  horse  by  the  injection 
of  toxins  or  attenuated  cultures;  that  is,  it  stimulates  the  patient 
to  produce  a  large  supply  of  antibodies  and  enables  him  to  resist 
disease.  This  action  differs  from  the  use  of  serums,  for  in  the 
latter  the  antibodies  are  supplied  directly  and  there  is  a  passive 
immunity,  while  in  the  use  of  vaccines  antibodies  are  manafactured 
in  the  body  and  there  is  an  active  immunity. 

The  literature  upon  the  subject  is  large  and  the  expressed 
opinions  differ  widely,  so  that  the  practical  working  out  of  the 
theories  has  not  reached  that  stage  yet  when  we  can  place  much 
reliance  upon  it. 

On  general  principles,  the  use  of  serum  is  indicated,  if  at  all, 
when  the  infection  is  generalized  and  vaccines  when  the  infection 
is  localized  strictly  or  when  the  general  infection  is  not  acute. 

From  a  broad  survey  of  the  literature,  we  gather  clearly  that 
the  vaccines  are  far  from  infallible  and  that  they  have  decided 
limitations.  They  are  at  best  in  children  auxiliary  means  of 
attempting  to  combat  infections  and  should  never  be  allowed  to 


236 


entirely  supplant  the  other  well-recognized  and  proved  methods  of 
medical  or  surgical  relief.  • 

Autogenous  vaccines  seem  to  be  no  more  efficient  than  stock 
vaccines  competently  prepared  and  which  are  certainly  much  easier 
to  obtain  and  cause  no  delay  in  applying  the  method  of  treatment. 

The  greatest  care  should  be  observed  to  have  the  syringe  per- 
fectly sterile  and  the  skin  about  the  part  to  be  subjected  to  injec- 
tion properly  prepared  according  to 
the  rules  of  adequate  antisepsis. 

There  is  no  set  guide  by  which 
we  may  determine  the  exact  dose 
needed  in  a  given  case  or  by  which 
we  can  clearly  indicate  the  need  of 
subsequent  injections.  However,  the 
clinical  manifestations  are  the  chief 
guides  both  as  to  the  size  of  the 
dose  and  the  necessity  for  its  repe- 
tition. 

Each  vaccine  is  selected  accord- 
ing to  the  particular  type  of  infec- 
tion, and  this  must  be  determined 
beforehand.  But  there  are  instances 
in  which  the  exact  nature  of  the  in- 
fection cannot  be  definitely  deter- 
mined, or  in  which  the  necessity  for 
immediate  action  does  not  allow  of 
much  investigation,  and  in  such  in- 
stances we  have  a  valuable  adjunct 
in  the  Combined  Bacterial  Vaccine  of  Van  Cott. 

We  must  emphasize  again  that  the  use  of  a  vaccine,  no  matter 
how  clearly  indicated,  or  how  carefully  selected,  should  not  take 
the  place  of  the  usual  and  well-recognized  methods  of  treatment, 
nor  should  its  use  deter  in  any  way  from  the  activity  of  such  means 
of  combating  the  infection. 

Bacterial  vaccines  are  adjuncts  to,  but  never  substitutes  for, 
the  medical  or  surgical  treatment  of  infections  in  childhood. 


FIG.  77. — SITES  FOR  INJECTION  OF 
SERA  OR  VACCINES  IN  CHILDREN. 


SECTION  VII 
INJURIES 


CHAPTER  XXXIII 

BURNS    AND    SCALDS 

The  frequency  with  which  the  surgeon  is  called  upon  to  treat 
burns  and  scalds  in  young  children  gives  the  subject  an  importance 
that  cannot  be  overlooked. 


FIG.  78. — PROPER  POSITION  FOR  THE  TREATMENT  OF  BURNS  INVOLVING  THE  NECK. 
The  head  should  not  be  thrown  forward  by  a  pillow,  but  a  roll  or  small  pillow  must  support 
the  shoulders. 

It  is  not  alone  the  ignorance  of  the  child  or  the  carelessness  of 
its  attendants  that  contribute  to  this,  but,  irrespective  of  these,  the 
skin  of  the  young  child,  being  so  much  more  delicate  than  that  of 
the  adult  and  its  proportionate  surface  being  so  much  more  ex- 
tensive, adds  a  further  element  of  easy  destruction.  Thus  we  find 
that  the  prognosis  of  burns  and  scalds  in  the  immature  is  much 
more  serious  than  in  later  life. 

237 


238 


BUKNS  AND  SCALDS 


Clinically  there  does  not  seem  to  be  any  apparent  difference  in 
the  effect  which  different  kinds  of  heat  have  upon  the  child's  tissues 
and  the  effect  from  a  flame,  a  heated  surface  in  direct  contact  with 
the  body,  or  radiated  heat  is  practically  the  same,  provided  the 
degree  of  heat  be  the  same. 

Scalding  is  apt  to  be  more  extensive  than  burning  and  also 
more  superficial,  but  this  is  determined  by  the  fact  of  the  more 
widespread  distribution  of  the  scalding  material  and  its  more  rapid 

cooling,  while  in  burns  the  heat  is  gen- 
erally applied  to  a  smaller  surface  and 
for  a  longer  time. 

There  is  no  practical  advantage  in 
attempting  to  classify  burns  or  scalds 
according  to  their  degrees  or  the  depth 
of  the  lesion.  Practically,  the  burns 
and  scalds  which  are  observed  at  the 
bedside  by  the  surgeon  are  of  a  mixed 
form,  being  a  combination  of  the  char- 
acteristics of  the  superficial  and  deeper 
injuries.  In  most  instances  the  injury 
is  to  the  skin  and  to  the  tissues  just 
beneath. 

Restoration  of  the  surface  to  its 
normal  condition  is  the  rule  if  infec- 
tion can  be  prevented.  But  in  most  in- 
stances infection  has  taken  place  early 
and  the  results  are  not  then  so  good,  as 
scarring  is  apt  to  occur  with  its  subse- 
quent unpleasant  and  disfiguring  results. 

Results. — The  pain  and  shock  which  accompany  even  limited 
burns  are  a  serious  matter  in  children  and  are  productive  of  grave 
results,  and  the  toxins  produced  in  the  tissues  affected  by  extensive 
burns  lead  to  rapidly  fatal  issues. 

There  is  always  one  inevitable  result  of  burns  or  scalds  in  child- 
hood— shock.  This  may  be  so  slight  as  to  be  scarcely  appreciable, 
or  may  cause  death  within  a  few  minutes.  Shock  depends  more 


FIG.  79. — INCORRECT  POSITION  IN 

BURNS  OF  THE  ARM  OR  AXILLA. 

In  this  position  contractures  are 

sure  to  occur  and  markedly 

limit  motion. 


RESULTS 


239 


upon  the  extent  of  the  burned  area  than  upon  its  depth,  and  this 
is  so  because  of  the  importance  of  the  cutaneous  surface  as  a  neces- 
sity to  perfect  functioning  of  organs  in  childhood,  and  the  fact  that 
a  cutaneous  nerve  injured  and  exposed  by  superficial  burning  causes 
more  pain  than  a  nerve  destroyed.  And  so  it  is  the  common  ex- 
perience in  children  to  find  that  burns  of  the  so-called  second  degree 
(because  of  the  reasons  stated)  show  the  highest  mortality.  The 
symptoms  are  the  usual  ones  of  shock  (see  page  106),  and  death  may 
occur  by  collapse  or  coma.  If  the  shock  is  not  severe,  or  if  severe 


FIG.  80. — CORRECT  POSITION  FOR  CHILD  WITH  EXTENSIVE  BURNS  OF  THE  ARM  OR  AXILLA 

and  the  child  recovers,  there  are  apt  to  be  several  days  of  fever,  irre- 
spective of  infection  or  complications. 

The  dangers  from  burns  or  scalds  are  many,  even  when  shock 
is  but  moderate.  Putrefactive  toxemia  may  early  add  to  the  danger 
to  life  and,  in  addition  to  this,  there  is  the  ever-present  danger  of  a 
mixed  infection  either  with  tetanus  or  erysipelas. 

Congestion  of  the  internal  organs  often  takes  place  in  some 
unexplained  manner  (some  claim  that  mere  destruction  of  the  skin 
is  responsible;  others  that  peripheral  irritation  is  the  cause,  and 
still  others,  blood  destruction,  capillary  thrombosis,  etc.),  and  adds 
to  the  symptomatology  and  the  unfavorable  prognosis.  Thus  we 
find  that  suppression  of  urine  is  common  at  all  stages  of  the  burn, 


BURNS  AND  SCALDS 

and  that  nephritic  congestion  is  most  common;  that  congestion  of 
the  brain  often  adds  its  unpleasant  symptomatology,  that  intestinal 
congestion  results  in  diarrhea  of  a  persistent  nature,  intestinal 
ulceration  or  hemorrhage,  or  that  any  one  or  all  of  the  organs  of 
the  body  suffer.  All  of  these  factors  render  the  outcome  more 
doubtful. 

Then  we  are  not  unmindful  of  the  disfiguring  scars  which  often 
result.     And  as  a  consequence  of  extensive  scarring  there  may  be 


FIG.  81. — AN  INCORRECT  AND  PARTICULARLY  BAD  POSITION  FOR  BURNS  (EVEN  MODERATE) 

OF  THE  PALM  OF  THE  HAND. 
A  useless  member  is  practically  certain  to  be  the  result  when  contracture  takes  place. 

actual  deformity  or  partial  loss  of  function  through  cicatricial  con- 
traction. 

More  remote  dangers  are  those  of  subsequent  chronic  ulceration 
or  keloid  growth. 

Diagnosis. — The  diagnosis  may  involve  close  observation  because 
the  history  may  be  absent  or  wilfully  withheld  or  denied  on  account 
of  possible  medico-legal  issues.  It  may  then  become  necessary  to 
make  a  distinction  between  a  burn  and  a  scald  and  in  the  latter 
the  hairs  are  not  destroyed  and  the  appearance  of  the  affected  sur- 
face is  quite  uniform. 

Wires  which  are  charged  with  electricity  make  the  burn  quite 
black  at  the  point  of  contact  and  this  point  is  surrounded  by  a 


DIAGNOSIS 


241 


paler  and  very  dry-appearing  area.  A  peculiarity  about  the  electric 
burn  is  that,  although  from  the  appearances  on  the  surface  the  burn 
may  not  seem  to  be  extensive,  the  involvement  of  the  deeper  struc- 
tures may  be  so.  Thus  considerable  caution  must  be  exercised  in 
making  a  prognosis. 

X-ray  burns  command  separate  comment.  The  deleterious 
effects  upon  the  skin  and  the  subcutaneous  tissues  and  even  of  the 
deeper  structures  are  an  established  fact.  It  is  not  infrequent  that 
the  first  indications  do  not  show  for  several  days  after  an  exposure, 
and  the  mildest  type  of  such  a  burn  is  evidenced  by  a  peculiar  blush 
or  redness  of  the  skin  which  resembles  a  sunburn.  This  continues 


FIG.  82. — INCORRECT  POSITION  FOR  HAND  IN  BURNS  OF  EVEN  MODERATE  DEGREE. 
This  position  is  better  than  that  in  Fig.  81  but  is  far  from  correct. 

for  several  days,  with  gradual  disappearance,  or  may  persist  for 
weeks.  Repeated  exposures  will  result  in  the  appearance  of  a  num- 
ber of  small  brown  or  blackish  freckles  and  a  slight  general  pig- 
mentation of  the  skin.  This  more  rarely  occurs,  even  after  a  single 
exposure.  Accidental  exposure  of  a  hair-covered  surface  may  cause 
temporary  falling  of  the  hair.  In  the  more  severe  types  of  X-ray 
burn,  the  erythema  is  succeeded  by  a  superficial  and  ill-defined 
vesication  and  associated  with  this  there  may  be  slight  swelling  of 
the  skin.  Usually  in  such  burns  the  general  symptoms  of  irritation 
are  added.  It  is  not  uncommon  to  observe  a  dry,  brawny  exfoliation 
follow  the  erythema. 


242 


BURNS  AND  SCALDS 


The  more  serious  burn  is  that  in  which,  for  some  unknown 
reason,  the  erythema  is  rapidly  succeeded  by  deep  ulceratiori  and 
sloughing.  The  ulcer  is  usually  covered  with  an  adherent,  grayish, 
leathery-looking  membrane  and  has  a  slightly  hyperemic  border. 
Pain  of  a  severe  character  is  the  rule  and  the  ulcer  shows  no 
tendency  to  spontaneous  healing. 

Prognosis. — The  prognosis  is  affected  directly  by  the  age,  for 
in  the  very  young  it  is  much  more  unfavorable  than  in  the  older 
child,  and  in  all  children  is  less  hopeful  than  in  adults.  There  are 
many  factors  which  must  receive  careful  consideration  in  making 

the  prognosis,  and  chief 
among  these  are  the  extent 
of  the  surface  involved,  the 
age  of  the  patient,  the  gen- 
eral nutrition  of  the  child, 
the  site  of  the  burn,  and 
the  possibility  of  avoiding 
complications. 

In  extensive  burns, 
even  after  recovery  from 
the  primary  shock,  life  is 
still  menaced  by  nephritis, 
uremia,  coma,  thrombus, 
and  duodenal  ulcer. 

In  burns  involving  over 

one-half  of  the  surface  of  the  body  death  usually  occurs  within  the 
first  twenty-four  hours  from  toxic  absorption. 

If  the  chest  or  abdomen  is  involved  to  any  considerable  extent, 
the  prognosis  is  grave,  because  even  relatively  small  burns  over 
these  areas  are  rapidly  destructive  to  life. 

If  infection  occurs  or  a  complication  is  added,  the  outlook  be- 
comes less  hopeful. 

Treatment. — The  treatment  comprises  local,  general,  and  sympto- 
matic care. 

The  GENERAL  TREATMENT  should  be  directed  at  once  toward 
combating  shock  (see  page  109),  and  for  this  purpose  there  is  no 


FIQ.  83. — CORRECT  POSITION  IN  BURNS  OP  THE 

PALM  OF  THE  HAND. 

Fingers  should  be  extended  and  separated  from  one 
another  and  held  so  by  proper  splints. 


TEEATMBNT  243 

single  drug  so  valuable  as  opium.  Immediate  small  doses  of  mor- 
phin  administered  hypodermically  relieve  the  pain,  steady  the 
nervous  system,  and  limit  or  prevent  vital  depression.  Heart 
stimulants  are  used  as  indicated  by  the  need.  Next  in  importance 


FIG.  84. — AN  INCOHBECT  POSTURE  FOB  THE  LEG  WHEN  IT  is  THE  SITE  OF  EXTENSIVE 

BUBNS. 

is  a  supply  of  fluids  to  compensate  for  the  great  loss  which  takes 
place  in  extensive  burned  surfaces  and  to  aid  in  the  elimination  of 
the  toxins.  This  is  best  accomplished  by  saline  injections  per 
rectum,  small  amounts  being  given  at  frequent  intervals. 

The  LOCAL  TREATMENT  demands  the  same  scrupulous  care  as  is 


FIG.  85. — COBBECT  POSITION  OF  THE  LEG  IN  EXTENSIVE  BUBNS. 

given  to  other  wounds  and  the  farther  the  local  treatment  of  burns 
is  removed  from  the  accepted  principles  of  wound  treatment  the 
less  satisfactory  will  be  the  results.  Since  septic  absorption  is  so 
large  a  factor  in  producing  fatal  results,  the  thorough  disinfection 
of  the  wound  and  the  application  of  such  dressings  as  will  facilitate 
and  not  hinder  or  retain  the  discharges  are  essential.  It  is  usually 


244 


BURNS  AND  SCALDS 


impossible  to  secure  thorough  cleansing  of  the  burn  without  an 
anesthetic.  Therefore  an  anesthetic  should  be  given  at  once  (this 
helps  also  to  limit  shock),  the  clothing  completely  removed,  and 
the  wound  surface  methodically  disinfected  with  a  boric  acid 
solution. 

.j^er^    * 

Blisters  should  be  opened  and  the  raised  epithelium  removed. 
The  wounded  surface  must  be  then  cleansed  of  all  devitalized 

tissue. 

In  the  choice  of  a  dressing  it 
is  at  once  obvious  that  any  appli- 
cation which  retains  the  dis- 
charges and  thus  promotes  septic 
absorption  is  irrational  and  dan- 
gerous, hence  ointments  and  pow- 
ders have  no  place  in  the  treat- 
ment of  burns.  It  is  time  that 
they  were  abandoned  and  rational 
measures  adopted. 

The  ideal  dressing  for  a  burn 
is  one  which  allays  the  pain,  pre- 
vents sepsis,  and  promotes  heal- 
ing : — these  characteristics  are 
admirably  exhibited  in  picric 
acid.  Make  a  solution  containing 
picric  acid,  one  and  one-half 
drams,  alcohol,  three  ounces,  and 
distilled  water,  forty  ounces. 
Moisten  gauze  compresses  with 

this  solution  and  apply  to  the  injured  surface  and  retain  them  there 
by  light  bandages. 

In  applying  the  dressings  considerable  care  must  be  taken  to 
overlap  the  edges  of  the  wounded  surface  so  that  ample  protection 
is  assured  against  marginal  infection  which  so  frequently  occurs. 

In  extensive  burns  the  whole  body  may  be  immersed  in  a  bath 

of  boric  acid  solution,  which  must  be  kept  at  the  body  temperature. 

The  prevention  of  deforming  cicatrices  is  no  minor  part  of  the 


FIG.  86. — THE  RESULTS  OF  INCORRECT 
POSITION  AND  DELAYED  SKIN  GRAFTING 
IN  EXTENSIVE  BURN  OF  THE  NECK. 

Note  the  deforming  as  well  as  the  dis- 
abling effects  of  inadequate  surgical 
treatment. 


TREATMENT 


treatment.  Even  after  the  patient  is  well  on  the  road  to  recovery 
he  is  still  menaced  by  the  possibility  of  contracting  cicatrices,  which 
not  only  deform  but  compromise  function.  However,  if  the  surgeon 
is  vigilant  many  deplorable  results  may  be  prevented  by  the  early  ap- 
plication of  adequate  prophylactic  measures.  The  following  sugges- 
tions are  important: 

(a)  In  the  arm  or  the  leg  the  use   of  splints  is  indicated  to 
hold  the  limb  in  the  opposite  direction  to  which  it  is  likely  to  be 
drawn  by  a  contracting  cicatrix. 

(b)  In  burns  of  adjacent  fin- 
gers the  dressing  should  embrace 
each  finger  separately  and  the  fin- 
gers  be   held   in   extension   by    a 
splint  to  prevent  cicatricial  syndac- 
tyly  and  deforming  flexures. 

(c)  Skin  grafting  is  the  best 
means  of  rapidly  healing  a  granu- 
lating surface   and  of  preventing 
cicatricial  contraction. 

This  valuable  adjuvant  is  too 
frequently  used  as  a  last  resort  to 
cover  in  granulating  surfaces 
which  refuse  to  heal  and  when  a  ci- 
catricial base  is  already  established. 
Skin  grafting  should  be  used 
early: — just  as  soon  as  a  healthy 

granulating  surface  is  established.  Small  Thiersch  grafts  should  be 
implanted  at  several  sittings.  Do  not  attempt  too  much  at  one 
operation.  Several  short  ether  narcoses  are  less  harmful  than  one 
long  one,  and  the  small  graft  frequently  applied  is  usually  the  short- 
est route  to  satisfactory  results. 

Even  with  the  greatest  care  burns  in  certain  regions  are  followed 
by  cicatricial  deformities.  This  is  notably  true  in  burns  about  the 
face  and  neck. 

Ectropion  often  follows  burns  of  the  eyelid.  Burns  of  the  lip, 
of  the  chin,  and  the  neck  draw  the  lip  downward,  depress  the  chin 


FIG.  87. — SIDE  VIEW  OF  SAME  CASE  AS 
FIGURE  86. 


246 

and  fix  it  on  the  sternum  (Fig.  87),  or  cause  various  deviations  of 
the  neck  to  one  side. 

These  ultimate  cicatricial  deformities  must  be  treated  on  the 
general  principles  which  govern  plastic  operations: — excision  of 
the  cicatricial  bands,  followed  by  grafting,  or  transplantation  of 
skin  flaps.  This  usually  ameliorates  the  deplorable  deformities. 

It  must,  however,  be  remembered  that  extensive  skin  plastics 
should  be  attempted  only  after  granulation  areas  are  covered  by 
scar  tissue. 

The  SYMPTOMATIC  TREATMENT  includes  the  management  of 
such  complications  as  diarrhea,  suppression  of  urine,  delirium,  etc. 
The  further  treatment  of  the  burned  area  is  that  of  any  crushed 
or  macerated  surface  and  the  principles  of  antisepsis,  asepsis,  and 
frequent  dressings  are  the  same. 

To  prevent  or  limit  contraction  and  impairment  of  function, 
all  large  granulating  surfaces  should  be  covered  with  skin  grafts 
and,  in  addition  to  this,  the  healing  surface  should  be  placed  in  a 
position  which  will  insure  the  greatest  usefulness  in  case  such  con- 
traction takes  place.  Usually  extreme  extension  will  be  found  the 
most  serviceable  position. 

It  is  always  advisable  in  children  to  dress  a  small  portion  of 
the  area  at  one  time,  leaving  the  rest  unexposed.  And  it  may  be 
well  to  reiterate  that,  in  the  subsequent  dressings  as  well  as  in  the 
first  one,  the  use  of  an  anesthetic  is  advisable  if  thorough  attention 
to  all  details  of  the  dressing  cannot  be  secured  without  it. 


CHAPTEE  XXXIV 

FRACTUKES  IN  CHILDREN 

The  child  is  an  unfinished  product.  Its  tissues  are  in  a  state 
of  plasticity.  The  bones  are  soft  and  elastic;  they  bend  without 
breaking,  just  as  the  young  sapling  will  bend  under  a  force  which 
would  break  the  mature  tree.  Furthermore,  the  ends  of  the  bones, 


PECULIARITIES 


247 


the  epiphyses,  act  as  elastic  buffers,  which  break  up  the  effects  of 
a  fall,  and  accommodate  themselves  to  considerable  pressure  with- 
out displacement.  Hence  dislocations  in  children  are  rare,  and 
the  force  that  in  an  adult  would  cause  a  dislocation,  in  a  child  is 
liable  to  result  in  fracture. 

The  great  majority  of  fractures  in  children  are  due  to  falls,  yet 
it  is  remarkable  how  extensive  the  fall  may  be  (down  a  flight  of 
stairs)  without  resulting  in  injury  to  the  bones. 


PECULIARITIES  OP  FRACTURE  IN  CHILDREN 

A.  Fractures  of  the  Newly  Born.— While  it  is  possible  for  intra- 
uterine  fractures   to  occur,  they   are  extremely  rare:  Fracture  is 
more  liable  to  occur  during  deliv- 
ery while  the  limbs  are  being  dis- 
engaged   (fracture   of   femur   or 

humerus),  or  as  a  result  of  the 
application  of  forceps  (depres- 
sions of  the  cranial  bones). 

B.  Fractures  Without  Dis- 
placement   (Subperiosteal    Frac- 
tures).— Owing  to  the  thickness 
of  the  periosteum  a  complete  f rac- 
t  u  r  e    without    displacement    is 
quite  frequent  in  the  first  years 
of    life.       These    fractures    fre- 
quently pass  unrecognized  and  it 
is  only  after  the  callus  has  formed 
an  obvious  swelling  that  the  pa- 
rents bring  the  child  to  the  doc- 
tor   for    consultation.      This    is 

notably  the  case  in  Sllbperiosteal     FIG.  88.— GREENS-TICK    FRACTURE    OF   THE 

„     ,         ,      .  ,          T,.  FOREARM. 

fractures  of  the  clavicle.     Diag- 
nosis is  often  difficult,  specially  as  all  other  signs  of  recognition  of 
the   fracture   may   be   absent    (deformity,    displacement,    crepitus). 


248  FRACTURES  IN   CHILDREN 

Only  by  means  of  the  X-ray  can  we  prove  a  lesion  heretofore  only 
suspected  through  swelling  and  pain.  Always  suspect  fracture  when 
children  refuse  to  use  their  extremities,  especially  where  their  atten- 
tion is  purposely  drawn  away  from  the  injury. 

C.  Incomplete  or  Greenstick  Fractures. — Here  the  break  is  only 
partial — like  a  green  stick  when  bent,  so  the  young  pliable  bone 
bends,  and  breaks  only  on  the  convex  side,  while  the  bony  tissue 
on  the  concave  side  remains  intact  (Fig.  88).     This  variety  of  frac- 
ture is  frequently  found  in  the  forearm  and  clavicle. 

D.  Separation  of  the  Epiphyses. — It    will    be    recalled    that    the 
long  bones  have  a  large  epiphysis  at  each  end  and  that  during  child- 
hood, and  prior  to  about  the  twentieth  year,  consolidation  of  the 
epiphysis  with  the  shaft  is  not  complete;  hence,  in  certain  injuries, 
the  epiphysis  is  separated,  or  becomes  "unglued"  from  the  shaft. 
It  is  obvious  that  this  lesion  can  take  place  only  during  the  period 
prior  to  the  time  of  ossification. 

E.  Exuberant  Callus. — While  the  production  of  callus  is  effected 
by  the  same  process  as  in  adults,  the  repair  is  more  rapid   (one- 
third  the  time  required  in  adults),  and  in  young  children  may  be 
so  exuberant  that  the  bony  swelling  simulates  an  actual  neoplasm. 
It  is  obvious  that  these  callous  swellings  may  easily  be  mistaken 
for  tumors  of  serious  import. 

F.  Fracture  Fever. — There  is  frequently  an  elevation  of  tempera- 
ture in  the  fractures  of  children,  especially  where  there  is  consider- 
able ecchymosis.      This   is  undoubtedly   due   to  the   absorption   of 
fibrin  ferment.     Its  practical  import  is  in  the  fact  that  it  is  often 
difficult  to  differentiate  between  fracture  and  osteomyelitis,  especially 
in  the  presence  of  a  subperiosteal  fracture  where  the  only  symptoms 
are  pain  and  fever. 

INTRAPARTUM  FRACTURES 

Fractures  occurring  during  delivery  are  of  sufficient  importance 
to  merit  special  consideration,  since  the  soft  plastic  body,  the  tender 
skin,  the  adipose  tissue  which  surrounds  the  bones,  the  problem  of 
keeping  the  dressing  clean,  all  present  formidable  difficulties  in 


INTRAPARTUM    FRACTURES 


249 


applying  and  retaining  splints  that  are  practically  efficient.  The 
usual  sites  of  fractures  occurring  during  delivery  are :  the  humerus, 
the  clavicle,  and  the  femur. 

Fracture  of  the  Humerus.  — Fracture  of  the  humerus  is  usually 
oblique  and  at  the  middle  of  the  diaphysis.  When  the  shortness 
of  the  arm  and  its  plasticity  are  considered,  it  is  obvious  that  the 
usual  methods  of  treatment  applicable  to  older  children  and  adults 
are  not  only  inefficient  but  impractical. 


FIG.  89. — DOUBLE  RECTANGULAR  SPLINT  AND  POSITION  OF  ARMS  WHEN  APPLIED,  IN 
FRACTURE  OF  THE  HUMERUS.     (After  Spitzy.) 


To  fix  the  arm  in  a  right-angle  splint  is  almost  impossible,  since 
the  arm  is  only  a  few  centimeters  in  length;  to  splint  the  arm  in 
permanent  extension  is  difficult,  since  a  bandage  tight  enough  to 
secure  the  arm  to  the  splint  will  in  practically  every  instance  cause 
edema  of  the  hand. 

The  only  satisfactory  solution  of  the  problem  has  been  sug- 
gested by  Spitzy,  who  fixes  the  elbow  at  right  angles  in  a  horizontal 
elevated  position  upon  a  long  double  rectangular  splint,  using  the 


250 


FRACTURES  IN   CHILDREN 


uninjured  arm  as  a  means  of  fixation.  The  splint  passes  across 
the  back  from  one  arm  to  the  other,  holding  the  arms  in  an  ele- 
vated horizontal  position,  the  forearm  being  flexed  at  a  right  angle 
(Fig.  89).  It  is  obvious  that  in  this  position  neither  the  move- 
ments of  the  child  nor  the  handling  which  its  care  necessitates  com- 
promise the  fixation  of  the  fragments. 

Fracture  of  the  Clavicle. — The  aim  in  the  treatment  of  fractured 
clavicle  is  to  prevent  the  shoulder  from  falling  forward  and  thereby 

obviate  overlapping  of 
the  fragments  and  angu- 
lar deformity.  The  same 
principle  is  used  in  ap- 
plying the  splint  here 
as  in  fractured  hu- 
inerus. 

An  inverted  _L  shaped 
splint  is  used,  passing 
across  the  back  and  em- 
bracing  the  forearms, 
which  are  flexed  at  a  right 
angle  and  held  in  a  hori- 
zontal position  (Fig.  90). 
In  this  position  the  arm  is 
rotated  outward,  the  an- 
terior portion  of  the  cap- 
sule of  the  ioint  is  held 

FIG.  90. — THE  INVERTED  J.-  SHAPED  SPLINT,   AND 

POSITION  OF  ARMS  WHEN  APPLIED  IN  FRACTURE     taut,  pulling  the  fragment 
OF  THE  CLAVICLE.     (After  Spitzy). 

outward     and     backward, 

and  thus  preventing  overlapping  and  angular  deformity. 

Fracture  of  the  Femur. — Fracture  of  the  femur  in  infants  pre- 
sents all  the  difficulties  presented  in  fracture  of  the  upper  extremity 
plus  the  serious  problem  of  keeping  the  dressings  unsoiled.  The 
choice  of  two  methods  may  be  made: 

(a)  The  thigh  may  be  placed  in  maximum  flexion  so  that  the 
knee  is  in  contact  with  the  body,  the  foot  over  the  shoulder.  Tin1 
extremity  in  this  position  is  fixed  by  bandages  to  the  abdomen. 


INTRAPARTUM    FRACTURES 


251 


While    this    postural    treatment    has    the    maximum    advantage    of 
cleanliness  the  results  are  not  always  satisfactory. 

(b)   The  authors  prefer  the  suggestion  of  Spitzy,  who   appre- 


FIG.  91. — SPLINTS  IN  POSITION  IN  FRACTURE  OF  THE  FEMUR.     (After  Spitzy.) 


FIG.  92.  —  DRESSING  COMPLETED  IN  FRACTURE  OF  FEMUR. 
Note  the  obvious  advantages  of  cleanliness,  comfort,  and  efficient  fixation.    (After  Spitzy.) 


JLLIESIZ   OF   OSTl£Ol= 


252          FRACTURES  IN  CHILDREN 

ciates  the  advantage  of  the  natural  biological  position  of  flexed  hip 
and  knee  joints  as  the  most  comfortable  for  the  child  and  the  most 
convenient  for  handling  it  in  caring  for  its  needs. 

This  position  is  maintained  by  an  anterior  splint  embracing 
both  extremities,  and  extending  from  a  point  corresponding  to  the 
lower  end  of  the  sternum  to  and  including  the  foot. 

The  apparatus  consists  of  two  strips  of  iron  one  inch  wide, 
united  at  one  end  by  a  rivet.  The  splints  are  bent  to  correspond 
to  the  curve  of  the  abdomen  and  the  anterior  aspect  of  the  lower 
extremity  in  its  natural  position  of  comfortable  flexion,  and  pro- 
longed at  right  angles  over  the  dorsum  of  the  foot  (Fig.  91).  To 

tjm 

this  splint  both  extremities  are  fixed.  The  advantages  are  obvious: 
cleanliness,  comfort,  and  efficient  fixation  (Fig.  92). 

TRAUMATIC  SEPARATION  OF  THE  EPIPHYSES 

Notwithstanding  the  fact  fyat  consolidation  of  the  epiphysis 
with  the  shaft  is  not  complete,  yet  it  must  be  remembered  that  it 
takes  a  tremendous  amount  of  force  to  separate  any  epiphysis  from 
its  adjoining  shaft ;  for  the  cartilaginous  connection  with  the  shaft 
is  reinforced  by  a  cuff  of  extremely  thick  periosteum,  and  a  greater 
force  is  necessary  to  cause  a  separation  of  the  epiphysis  than  is  re- 
quired to  fracture  the  bone.  It  is  rare  that  the  epiphysis  separates 
without  tearing  off  a  piece  of  bone  belonging  to  the  shaft.  The 
X-ray  has  shown  that  many  so-called  epiphyseal  separations  are 
actually  fractures  in  the  neighborhood  of  the  epiphyseal  line.  Con- 
trary, therefore,  to  popular  belief,  true  epiphyseal  separation  is 
extremely  rare.  It  is  always  the  result  of  great  violence  and  torsion, 
and  is  usually  produced  by  indirect  force.  The  lesion  is  most  fre- 
quent between  the  ages  of  ten  and  fifteen. 

A  point  of  great  practical  interest  is  the  effect  which  epiphyseal 
separation  has  upon  the  growth  of  the  limb.  As  Poland  has  shown, 
arrest  of  growth  is  comparatively  rare;  yet  the  prognosis  of  these 
injuries  must  always  be  given  with  caution,  and  the  possibility  of 
shortening,  even  in  cases  with  slight  displacement,  must  not  be 
minimized. 

G3T2G   ^0   SfjBJJO  : 


TEAUMATIC    SEPAKATION   OF   THE   EPIPHYSES 


While  it  is  possible  for  any  epiphysis  to  be  separated,  it  is  prac- 
tical to  consider  only  those  that  occur  most  frequently.  According 
to  Poland  the  order  of  frequency  of  the  principal  varieties  may  be 
classed  as  follows: 

1.  The  upper  epiphysis  of  the  humerus. 

2.  The  lower  epiphysis  of  the  femur. 

3.  The  lower  epiphysis  of  the  radius. 

4.  The  lower  epiphysis  of  the  humerus. 

5.  The  lower  epiphysis  of  the  tibia. 

6.  The  upper  epiphysis  of  the  tibia. 

Separation  of  the  Tipper  Epiphysis  of  the  Humerus. — The  upper  epi- 
physis includes  the  head  and  tuberosities,  and  is  represented  by 
a  line  which  follows  the  lower  half  of  the  anatomical  neck,  and  then 
diverges  outward  to  a 
point  represented  by  the 
insertion  of  the  teres  minor 
muscle.  (Fig.  93.)  It 
will  thus  be  seen  that  the 
end  of  the  diaphysis  .fits 
into  its  epiphysis  like  a 
wedge.  It  unites  with  the 
shaft,  at  from  the  twenti- 
eth to  the  twenty-fourth 
year.  Epiphyseal  separa- 
tion of  the  upper  end  of 
the  humerus  is  extremely 
rare  in  children,  except  in 
those  constitutional  affec- 
tions, such  as  rickets,  ma- 
r  a  s  m  u  s  ,  syphilis,  and 
scurvy,  where  slight  violence  may  cause  separation  without  displace- 
ment. Traumatic  separation  is  caused  by  some  severe  indirect  vio- 
lence— such  as  a  fall  from  a  height,  the  force  being  transmitted 
through  the  hand ;  or  catching  the  limb  in  a  revolving  wheel. 

The  displacement  is  characteristic.     The  head  of  the  bone  is  in 


B 


FIG.  93. — A.  SHOWS  LINE  OF  UPPER  EPIPHYSIS  OF 
HUMERUS.  B.  SHOWS  HOW  THE  END  OF  THE 
DIAPHYSIS  FITS  INTO  ITS  EPIPHYSIS  LIKE  A 
WEDGE. 


254 


FRACTURES  IN   CHILDREN 


place,  but  rotated  outward  by  the  action  of  the  muscles  attracted  to 
the  greater  tuberosity.  (Fig.  94.)  The  shaft  is  drawn  forward  and 
inward  by  the  muscles  attached  to  the  bicipital  groove.  The  upper 
end  of  the  shaft  can  be  felt  at  the  front  of  the  shoulders  and  is 
sometimes  seen  beneath  the  skin.  This  gives  rise  to  an  abrupt  pro- 
jection at  the  front  of  the  joint  a  short  distance  below  the  coracoid 
process  (Gray).  When  the  arm  is  rotated  crepitus  is  felt  but  it  is  of 
a  soft  cartilaginous  character.  The  periosteum  is  not  entirely  torn 
across;  portions  of  it  may  fall  between  the  fragments  and  prevent 
complete  reduction.  This  injury  sometimes  brings  about  prema- 


FIG.  94. — TRAUMATIC  SEPARATION  AT  THE  UPPER  EPIPHYSIS  OF  HTJMERUS. 

ture  ossification,  and,  as  the  growth  of  the  humerus  in  length  i-s 
chiefly  through  the  upper  epipliysis,  arrest  of  growth  may  follow. 
(Fig.  95.) 

Caution. — This  injury  is  liable  to  be  mistaken  for  a  dislocation 
of  the  shoulder.  To  avoid  this  error  remember  the  general  rule 
that  dislocations  in  children  are  extremely  rare  and  that  injuries 
about  the  joint  are  either  epiphyseal  separations  or  fractures  near 
the  joint.  Besides  this  general  rule  the  evidence  in  favor  of  frac- 
ture is  found  in  the  preternatural  mobility  and  crepitus.  The  value 
of  the  X-ray  is  evident. 


TRAUMATIC    SEPARATION   OF   THE   EPIPHYSES     255 


Treatment. — When  the  displace- 
ment is  slight  abduction  and  traction 
under  anesthesia  are  sufficient  to 
bring  the  separated  parts  in  line. 
After  reduction  the  shoulder  and  arm 
should  be  immobilized  in  a  Velpeau 
bandage  of  plaster  of  paris.  There 
are,  however,  certain  displacements 
which  cannot  be  reduced  without 
operative  assistance.  The  torn  peri- 
osteum falls  between  the  fragments, 
the  end  of 
the  diaphysis  is 
buried  in  the 
muscle  mass, 
and  manipula- 
tion reduction  is 
futile.  It  will 
be  necessary  in 
such  cases  to 
make  an  inci- 
sion and  clear 


.  95. — ARREST  OF  DEVELOP- 
MENT OF  RIGHT  ARM  DUE  TO 
EARLY  TRAUMATIC  SEPARATION 
OF  THE  EPIPHYSEAL  CARTILAGE. 
(Helferich.) 


FIG.  96. — SHOWING 
EPIPHYSES  OF  FEMUR. 


away  the  intervening  soft  parts  that  prevent 
reduction ;  in  some  instances  it  may  be  neces- 
sary to  resect  the  head  of  the  bone. 

Separation  of  the  Lower  Epiphysis  of  the 
Femur.  — Recall  the  fact  that  the  lower  epi- 
physis  of  the  femur  includes  all  of  the  articu- 
lar surface  of  the  lower  end  of  the  femur  with 
the  attachments  of  the  gastrocnemius  muscle. 
The  line  of  the  epiphysis  passes  transversely 
across  just  above  the  edge  of  the  articular 
surface.  (Fig-  96.)  It  joins  the  shaft  of 
the  bone  at  about  the  twenty-first  year.  It 
is  evident  that  the  knee  joint  depends  for 
its  support  upon  its  ligaments  and  surround- 


256 


FRACTURES  IN   CHILDREN 


ing  fascia,  thus,  any  strain  upon  the  knee  joint  is  transmitted  to 
the  ligaments  attached  to  the  lower  femoral  epiphysis  and,  if  suffi- 
cient force  is  applied,  the  epiphyseal  cartilage  is  detached.  This 
accident  is  due  to  great  violence  and  twisting  of  the  joint.  In  a 
large  number  of  instances  it  has  followed  the  vicious  practice  of 

catching  on  behind  a  moving  vehicle,  and 
getting  the  leg  caught  in  the  spokes  of 
the  revolving  wheel. 

The  displacement  of  the  epiphysis 
is  usually  forward.  (Fig.  97.)  Some- 
times the  injury  is  compounded  by  the 
end  of  the  diaphysis  protruding  back- 
ward through  the  skin.  Injury  to  the 
popliteal  vessels  has  resulted  in  aneurysm 
and  gangrene  of  the  leg. 

Diagnosis. — This  injury  may  be  mis-/ 
taken  for  a  dislocation  of  the  knee  or  a 
supracondyloid  fracture  of  the  femur. 
Remember  that  dislocation  in  children  is 
rare.  The  character  of  the  crepitus  in 
supracondyloid  fracture  is  hard  and 
bony,  in  epiphyseal  separation  it  is  soft 
and  cartilaginous.  Careful  attention  to 
the  history  of  the  injury  is  important. 
Epiphyseal  separation  is  always  followed 
by  considerable  shock  and  great  swelling. 
The  value  of  X-ray  examination  is  obvi- 


FIG.  97. — SEPARATION   OF  LOWER 


OUS. 


EPIPHYSIS    OF  THE   FEMUR — 

THE     EPIPHYSIS    DISPLACED         Treatment. — If  the  separation  is  1111- 

FORWARD,     THE     END     OF    THE 

DIAPHYSIS  PROTRUDING  BACK-  complicated     reduction     should     be     at- 
tempted  by   flexing  the   leg   to   a   right 

angle  and  making  traction  and  countertraction  on  leg  and  thigh. 
After  reduction  is  complete  the  limb  should  be  kept  in  a  position  of 
flexion  to  assist  in  retaining  the  epiphysis  in  position,  and  im- 
mobilized in  a  plaster-of-paris  splint.  After  three  or  four  weeks  the 
leg  may  be  gradually  extended.  The  plaster  is  removed  after  six 


TEAUMATIC   SEPARATION   OF  THE   EPIPHYSES     257 


weeks;  after  ten  weeks  the 
patient  may  be  allowed  to 
walk.  If  attempts  at  reduc- 
tion are  unsuccessful  it  will 
be  necessary  to  clear  the 
fragments  of  obstructing 
bands  and  reduce  through  an 
open  incision.  In  extreme 
cases  it  may  be  necessary  to 
resect  the  end  of  the  diaphy- 
sis.  If  the  separation  is  com- 
plicated by  an  open  wound  or 
the  vessels  are  torn  such  sur- 
gical measures  must  be  insti- 
tuted as  the  case  demands. 
Shortening  is  to  be  expected ; 
the  amount  depends  upon 
the  severity  of  the  injury. 
Separation  of  the  lower  epi- 
physis  of  the  radius  is  a  very 
infrequent  lesion.  The  epiphy- 
sis  unites  with  the  shaft  of  the 
bone  at  the  twentieth  year  and 
prior  to  this  time  the  separated 
epiphysis  simulates  Colles'  frac- 
ture. While  the  lesion  is  pro- 
duced like  a  Colles'  fracture  by 
falling  on  the  extended  hand,  the 
break  is  nearer  the  line  of  the 
joint,  there  is  no  impaction,  and 
the  relative  position  of  the  sty- 
loid  process  is  not  disturbed. 

Reduction  of  a  separation  of 
the  epiphysis  is  simple,  the  frag- 
ments are  easily  held  in  posi- 
tion, and  the  healing  is  prompt. 


FIG.  98. — LOWER  EPIPHYSIS  OF  THE  HUMERUS  ; 
CENTERS  OF  OSSIFICATION  OF  CAPITELLUM  ; 
AND  INTERNAL  CONDYLE. 


FIG.  99. —  THE  NORMAL  EPIPHYSEAL 
LINE  AT  UPPER  END  OF  TIBIA  AND 
FIBULA 


258  FRACTURES  IN   CHILDREN 

Separation  of  the  Lower  Epiphysis  of  the  Humerus. —  The  lower 
epiphysis  of  the  humerus  is  composed  of  the  external  epicondyle, 
the  capitellum,  and  the  trochlear.  (Fig.  98.)  These  separate  centers 
of  ossification  unite  about  the  thirteenth  year,  and  about  the  seven- 
teenth year  they  join  the  shaft  of  the  bone  (Scudder).  It  is  rare  to 
find  a  true  epiphyseal  separation  from  injuries  of  the  elbow  since 
traumatism  generally  produces  a  fracture  and  not  an  epiphyseal  sepa- 
ration. When  such  separation  occurs  it  is  usually  in  very  young 
children  (see  fracture  of  the  elbow). 

Separation  of  the  Lower  Epiphysis  of  the  Tibia. —  This  is  very 
rare.  It  is  usually  accompanied  by  a  fracture  of  the  fibula,  simu- 
lates Pott's  fracture,  and  the  treatment  is  the  same. 

Separation  of  the  Upper  Epiphysis  of  the  Tibia. — It  will  be  re- 
called that  the  upper  epiphysis  of  the  tibia  runs  transversely  across 
the  tibia  about  one-half  inch  below  the  articular  surface  and  passes 
down  anteriorly  in  a  tongue-shaped  process  to  include  the  tubercle. 
(Fig.  99.)  Scudder  demonstrates  "that  many  apparent  trivial  in- 
juries— such  as  violent  contraction  of  the  quadriceps  extensor  muscle 
— a  blow  to  the  region  of  the  tubercle  of  the  tibia,  result  in  partial 
separation,  with  or  without  some  displacement  of  the  tongue-shaped 
portion  of  the  upper  epiphysis  of  the  tibia."  This  lesion  is  not  un- 
usual in  young  athletic  adults,  and  when  there  is  no  displacement  it 
is  of  the  nature  of  an  epiphyseal  sprain.  Protective  immobilization 
of  the  knee  is  usually  sufficient  to  effect  a  cure. 


SECTION  VIII 

SURGICAL  DISEASES  OF  THE  CENTRAL 
NERVOUS  SYSTEM 

CHAPTER  XXXV 

INJURY    AND    DISEASE    OF    THE    SPINAL    CORD    AS    EVIDENCED    BY 

SYMPTOMS 

While  there  is  usually  a  more  or  less  complicated  admixture  of 
prominent  and  characteristic  symptoms  in  either  injury  or  disease 
of  the  spinal  cord,  it  is  still  most  practical  to  consider  these  indi- 
vidually in  so  far  as  they  are  connected  with  conditions  that  may 
be  amenable  to  surgical  relief. 

These  symptoms  are  paralysis,  changes  of  gait  and  of  posture, 
disturbances  of  the  anal  and  vesical  sphincters,  ataxia,  disturbances 
of  motor  or  sensory  reflexes,  disturbances  of  sensation,  pain,  vaso- 
motor  and  trophic  disturbances. 


PARALYSIS 

As  the  result  of  either  an  injury  or  disease,  paralysis  may  ex- 
hibit itself  in  the  form  of  weakness  or  a  total  loss  of  power  in  one 
muscle,  a  group  of  muscles,  or  an  entire  limb. 

What  is  sometimes  called  "false  paralysis"  must  not  be  mis- 
taken for  paralysis,  for  inhibition  of  the  muscular  function  pro- 
duced by  disease  which  causes  pain  upon  motion  is  by  no  means  a 
paralysis,  although  it  so  often  simulates  it. 

According  to  the  type  of  the  paralysis,  we  have  spastic  paralysis 
(evidenced  by  an  increase  in  the  muscular  tone,  an  exaggeration 
of  the  reflexes,  etc.)  and  flaccid  paralysis  (in  which  the  muscular 

259 


260        INJUKY  AND  DISEASE  OF  THE  SPINAL  CORD 

tone  is  diminished,  the  reflexes  decreased  or  abolished,  and  no  re- 
sistance offered  to  passive  motion).  In  considering  the  injuries  or 
surgical  diseases  of  the  spinal  cord,  it  is  quite  essential  that  we 
clearly  distinguish  between  these  two  prominent  types  of  paralysis, 
as  this  often  gives  us  a  valuable  clew  as  to  the  probable  cause. 

For  instance,  paralysis  may  occur  as  the  result  of  some  injury 
or  disease  of  the  cerebral  cortex,  or  of  lesions  in  the  motor  paths 
at  any  point  between  the  cortical  motor  center  and  the  motor  cells 
of  the  anterior  horns  of  the  gray  matter  of  the  spinal  cord. 

Paralysis  dependent  upon  injury  or  disease  affecting  the  lateral 
pyramidal  and  anterior  median  column  motor  paths  is  known  as 
corticospinal  (or  central  neuron)  paralysis,  while  that  due  to 
lesions  on  the  motor  cells  of  the  cord  itself  is  designated  as  spino- 
muscular  (or  peripheral  neuron)  paralysis. 

It  is  the  clinical  manifestations,  however,  with  which  we  are 
most  concerned,  and  these  vary  according  as  the  lesion  acts  as  an 
inhibitory  or  as  a  destructive  force  upon  the  central  or  upon  the 
peripheral  neuron. 

The  clinical  manifestations  which  distinguish  these  are  as 
follows : 

Central  Neuron  Lesion  Peripheral  Neuron  Lesion 

Paralysis  with  rigidity.  Paralysis  with  flaccidity. 

Increased  tendon  reflexes.  Loss  of  all  reflexes. 
Loss  of  peripheral  reflexes. 

Atrophy  slight  or  absent.  Atrophy  early  or  marked. 

Trophic  changes  slight.  Trophic  changes  marked. 

Electrical  reaction  preserved.  Electrical  reaction  degenerated. 

It  must  be  recalled,  however,  that  this  rather  distinctive  char- 
acter of  the  paralysis  is  not  always  evident  immediately  after  an 
injury  or  a  rapidly  acquired  lesion,  but  that  occasionally  a  period 
of  several  hours,  or  more  rarely  of  two  or  three  days,  must  elapse 
before  the  really  distinctive  features  are  evident. 

Monoplegia  may  be  closely  simulated  by  immobility  of  the  limit, 
which  is  entirely  dependent  upon  the  fear  of  pain  which  is  caused 
by  motion,  or  on  an  immobility  from  epiphyseal  separation. 


PARALYSIS  201 

In  an  older  child  pain  would  be  complained  of,  but  in  the  case 
of  an  infant  the  parent  might  easily  make  misstatements.  Irrespec- 
tive of  the  history,  an  examination  including  passive  motion  would 
determine  the  difference.  With  epiphyseal  separation  there  are  more 
or  less  crepitation  and  an  enlargement  at  the  ends  of  the  long  bones. 
The  estimation  of  muscular  tone  has  been  fully  considered  in 
another  chapter. 

On  account  of  its  importance  to  the  surgeon,  we  might  consider 
these  a  little  more  in  detail. 

Corticospinal  Paralysis.- — In  this  type  there  is  not  always  an  ab- 
solute paralysis,  although-  the-  musculature  is  more  or  less  rigid  and 
the  joints  are  moved  with  some  resistance.  Percussion  of  the  tendon 
of  the  muscle  and  sometimes  of  the  muscle  itself  will  promptly 
result  in  contraction.  The  general  appearance  of  the  limb  is  not 
one  of  atrophy,  although  there  is  commonly  more  or  less  impaired 
circulation  with  consequent  blueness  and  coldness  and  occasionally 
a  marked  edema.  Sensation  remains  normal  when  allowances  have 
been  made  for  the  influence  of  a  defective  circulation  and  the  pos- 
sible edema,  both  of  which  in  part  destroy  the  normal  sensitiveness 
of  the  cutaneous  surface.  As  has  been  stated,  the  electrical  reaction 
remains  normal.  Such  a  paralysis  is  common  as  the  result  of 
cerebral  injury  or  disease  and  is  evidenced  as  a  hemiplegia,  but 
if  it  originates  in  the  cord  and  is  due  to  some  transverse  lesion 
the  paralysis  will  affect  both  lower  limbs,  or,  in  a  cervical  lesion, 
both  arms.  Thus  it  is  encountered  in  some  cases  of  Pott's  disease, 
pressure  (tumor  or  other  lesion),  after  hemorrhage,  and  in  the  soft- 
ening following  thrombosis. 

Spinonmscular  Paralysis. — In  this  type  there  is  an  absolute 
paralysis  and  if  recovery  takes  place  at  all  it  is  only  after  a  very 
long  period. 

In  contradistinction  to  the  corticospinal  type  of  paralysis,  which 
affects  quite  uniformly  all  the  muscles  of  a  limb  or  part,  the  spino- 
muscular  type  affects  distinct  groups  of  muscles,  and,  if  all  of  the 
musculature  of  a  limb  be  affected  at  first,  there  is  great  probability 
that  rapid  recovery  will  be  quickly  evidenced  in  most  of  the  muscles. 
The  flaccidity  of  the  musculature  allows  of  free  passive  motion  of 


262        INJURY  AND  DISEASE  OF  THE  SPINAL  CORD 

the  limb  and  the  looseness  of  the  joints  allows  of  over-motion.     Per- 
cussion fails  to  bring  about  any  contractions. 

The  general  appearance  of  the  limb  is  one  of  atrophy,  which 
occurs  early  and  is  persistent.  This  is  accompanied  by  more  or 
less  marked  blueness  and  coldness.  Sensation  may  or  may  not  be 
impaired.  The  reaction  of  degeneration  is  evidenced  by  the  use 
of  the  electrical  current. 

This  type  of  paralysis  may  be  observed  in  tumors,  hemorrhages, 
or  softening  of  the  cord,  and  in  some  forms  of  myelitis.  While  its 
common  occurrence  is  in  disease  which  is  not  amenable  to  surgical 
intervention,  its  characteristics  are  important  to  remember,  so  that 
differentiation  may  be  possible  from  paralysis  dependent  upon 
lesions  of  the  peripheral  nerves. 

General  Character  of  Paralysis  Following  Injury  or  Disease  of  the 
Spinal  Cord. — Generally  speaking,  there  are  two  forms  of  paralysis 
which  follow  injury  of  the  spinal  cord  and  these  depend  upon  the 
extent  of  the  injury;  that  is,  whether  there  has  occurred  complete 
or  incomplete  destruction.  As  the  latter  is  the  only  one  amenable 
to  successful  surgical  treatment,  it  is  most  important  that  the  dis- 
tinction between  the  two  forms  be  clearly  made. 

A  complete  destruction  of  the  spinal  cord  at  any  level  results 
at  once  in  complete  paralysis  of  the  musculature  below  that  level. 
There  is  flaccidity  (peripheral  neuron  type)  and  not  rigidity.  The 
loss  of  tendon  and  muscle  reflex  is  complete  and  persistent  and 
there  is  no  appreciable  difference  between  the  two  sides  of  the  body, 
either  as  regards  this  feature  or  the  paralysis.  Loss  of  sensibility 
to  pain,  to  changes  of  temperature,  and  generally  to  touch  is  evi- 
denced over  a  very  definite  surface.  Vasomotor  paralysis  is  also 
prominent.  There  is  also  retention  of  urine. 

Upon  the  other  hand,  in  an  incomplete  destruction,  the  one  that 
may  be  helped  by  surgery  (as  when  the  cord  is  compressed  or  con-' 
tused),  there  is  also  a  complete  paralysis  below  the  level  of  the 
lesion,  but  this  is  accompanied  by  muscular  rigidity  and  an  in- 
crease in  the  tendon  and  muscle  reflexes.  It  is  not  uncommon  also 
to  note  evidences  of  partial  involvement  of  the  wall  of  the  bowel. 
There  is  loss  of  bladder  control. 


DISTURBANCES  OF  SPHINCTER  CONTROL     203 

We  can  see  from  this  how  very  important  it  is  that  the  two 
types  be  kept  clearly  in  mind  and  the  differentiation  made  at  the 
time  of  the  injury,  so  that  the  possibility  of  surgical  relief  may  be 
considered. 


DISTURBANCES   OF   ANAL   AND   VESICAL   SPHINCTER 

CONTROL 

Disturbances  of  the  sphincter  control  of  the  anal  and  vesical 
regions  are  the  very  common  accompaniments  of  all  injuries  and 
diseases  which  affect  the  spinal  cord.  They  are  also  one  of  the 
most  distressing  features,  both  to  the  patient  and  his  attendants. 

The  reflex  mechanism  controlling  these  parts  is  situated  in  the 
fourth  and  fifth  sacral  segments  of  the  cord.  The  function  is  two- 
fold. Sensory  impulses  received  by  the  cord  from  distention  of 
the  bladder  or  the  rectum  cause  an  inhibitory  influence  to  be  exerted 
upon  the  contractions  of  the  vesical  and  anal  sphincters,  so  that  they 
relax  and,  in  addition  to  this,  there  are  stimulation  and  contrac- 
tion of  the  detrusor  muscles.  This  dual  action  causes  the  contents 
of  the  bladder  or  the  rectum  to  escape.  This  mechanism  may  be  so 
disturbed  by  injury  or  disease  of  the  cord  that  these  centers  may 
be  cut  off  from  the  controlling  influence  of  the  brain  and  act  auto- 
matically, or  the  bladder  and  rectum  may  empty  themselves  involun- 
tarily, but  at  intervals;  this  latter  being  known  as  "active  incon- 
tinence." But  if  there  is  a  destruction  of  the  centers  in  the  sacral 
segments,  there  is  complete  incontinence. 

These  disturbances  of  bladder  and  rectum  activity  are  very  com- 
mon to  all  injuries  and  diseases  of  the  spinal  cord  and  by  their 
existence  add  a  real  danger  of  subsequent  infection  through  the 
necessity  for  instrumental  relief. 

Of  course,  the  rectum  may  be  mechanically  emptied  over  a  long 
period  without  any  serious  consequences,  but  it  not  uncommonly 
happens  that  this  method  of  relief  is  not  always  successful  without 
the  danger  of  injury  to  the  parts. 


264       INJURY  AND  DISEASE  OF  THE  SPINAL  COED 

ATAXIA 

Disturbances  of  the  muscular  sense  and  loss  of  muscular  co- 
ordination are  observed  in  nonsurgical  lesions  of  the  cord  quite  com- 
monly, but  the  surgical  conditions  under  which  they  are  most  fre- 
quently encountered  are  tumors  of  the  cord,  or  growths  in  the 
meninges,  which  press  upon  the  posterior  columns  of  the  cord. 

The  characteristic  ataxic  gait  is  evidenced  by: 

(1)  An  uncertain  placing  of  the  feet  with  steps  of  very  irregu- 
lar length. 

(2)  The  tendency  to  lose  the  balance. 

(3)  In  the  more  advanced  stages  the  step  may  resemble  a  kick 
forward  with  the  feet  widespread. 

Closure  of  the  eyes  renders  the  ataxia  more  marked,  so  that 
the  consequent  swaying  of  the  body  compels  the  child  to  open  the 
eyes  to  maintain  its  balance. 

Very  young  children  become  so  easily  discouraged  with  an 
ataxic  gait  that  they  are  very  prone  to  make  no  further  attempts 
to  walk,  so  that  the  surgeon  must  remember  that  an  apparent 
paralysis  following  ataxia  may  be  dependent  not  upon  inability  but 
upon  disinclination. 

Habit  is  unusually  strong  during  the  earlier  periods  of  life,  and 
it  is  not  uncommon  after  a  real  physical  disability  has  been  en- 
tirely cleared  up  to  find  that  the  child  has  acquired  a  habit  from 
his  previous  disability,  and,  in  neurotic  individuals,  this  may  be 
persistent. 

The  peculiar  gait  which  is  the  result  of  the  ataxia  seems  to 
deeply  interest  some  children  when  they  are  convalescent,  and  this 
leads  to  persistent  imitation  of  the  real  physical  disability,  with  the 
consequent  formation  of  habit  disability. 


DISTURBANCES  OF  MOTOR  AND  SENSORY  REFLEXES 

If  lesions  of  the  peripheral  nerves  can  be  positively  eliminated 
as  the  cause,  a  loss  of  tendon  reflexes  indicates  a  lesion  situated  in 


MOTOR   AND    SENSORY    REFLEXES  s>G5 

that  segment  of  the  cord  which  presides  over  the  particular  reflex 
in  question.  This  gives  peculiar  value  to  this  means  of  diagnosis, 
as  it  aids  materially  in  the  determination  of  the  definite  level  at 
which  we  will  find  the  lesion.  Exaggeration  of  the  tendon  reflexes 
indicates  that  the  inhibitory  control  of  the  brain  over  the  cord  has 
been  disturbed,  and,  as  a  result,  the  cord  reacts  more  readily  to 
sensory  impulses  and  to  clonus  results. 

Without  going  into  a  consideration  of  all  reflex  actions,  most 
of  which  are  in  common  usage,  certain  special  signs  of  nervous 
irritability  must  be  mentioned. 


FIG.  100. — TESTING  THE  KNEE  REFLEXES. 
Whenever  possible  this  should  be  done  with  a  percussion  hammer. 

Babinski's  Sign. — Babinski  found  that  in  disease  of  the  motor 
tract  dorsal  flexion,  i.  e.,  extension  of  the  great  toe,  resulted  from 
reflex  irritation  on  the  sole  of  the  foot.  Normally,  two  reflexes 
may  be  obtained  by  irritation  of  the  sole:  (a)  plantar  flexion,  and 
(b)  dorsal  flexion  of  the  toes  and  combined  movements  of  the  leg, 
due  to  a  strong  stimulus.  In  Babinski's  sign  dorsal  flexion  results 
from  a  slight  stimulus  and  therefore  the  spinal  reflex  is  exaggerated. 

It  may  be  due  to  increased  excitability  of  the  cord  from  the 
administration  of  strychnin,  or  diminished  excitability  of  the  cortex 
from  depressing  drugs,  or  conditions  of  the  system  which  result  in 
more  or  less  stupor.  The  sign  does  not  necessarily  mean  that  there 


266         INJURY  AND  DISEASE  OF  THE  SPINAL  CORD 

is  disease  of  the  motor  tract.  It  is  constantly  present  in  the  newly 
born  and  persists  with  more  or  less  certainty  up  to  two  years,  and, 
occasionally,  beyond  that  period,  so  that  the  sign  has  practically  no 
value  before  the  third  year  of  life  is  ended. 

In  children  over  the  age  of  three  the  sign  may  have  some  value 
as  it  is  absent  in  hysteria,  while  other  tendon  reflexes  are  apt  to 
be  much  exaggerated. 

Sensory  disturbances  are  difficult  to  estimate  in  children.  The 
skin  reflexes  are,  however,  commonly  lost  or  disturbed  in  those 
instances  in  which  the  tendon  reflexes  are  increased,  but  taken  as 
a  whole,  on  account  of  the  difficulty  of  accurate  determination  in 
childhood,  they  are  of  greatly  less  value  than  the  tendon  reflexes. 


DISTURBANCES    OF    SENSATION 

These  are  quite  difficult  of  recognition  in  the  very  young  and, 
even  in  those  children  who  are  older  and  of  average  intelligence, 
there  is  an  uncertainty  because  of  their  inability  to  accurately  de- 
scribe or  locate  sensations. 

Sensations,  such  as  heat  or  cold,  numbness,  tingling,  fulness, 
pressure  or  weight,  may  be  produced  in  the  skin  by  irritation  of 
the  sensory  areas  of  the  cord  and  such  sensations  may  affect  the 
whole  or  a  part  of  the  limb.. 

A  destruction  of  the  sensory  areas  in  the  cord  leads  to  anesthesia, 
which  will  be  complete  if  the  sensory  areas  are  entirely  destroyed 
at  the  level,  or  if  the  posterior  nerve  roots  are  cut  or  destroyed. 
With  an  incomplete  injury  to  the  sensory  areas  in  the  cord,  there 
result  a  loss  of  some  kinds  of  sensation  and  the  retention  of  tlie 
others. 

Loss  of  tactile  sensation  (the  sense  of  touch)  always  suggests  a 
widespread  degeneration  in  the  anterolateral  and  posterior  columns 
of  the  cord. 

Analgesia  (loss  of  the  sense  of  pain)  and  thermoanalgesia 
(loss  of  the  sense  of  temperature)  indicate  a  lesion  of  the  central 
gray  matter  and  of  the  ascending  anterolateral  fibers. 


VASOMOTOE    AND    TROPHIC    DISTURBANCES        267 

Ataxia  (loss  of  the  muscular  sense)  is  indicative  of  a  lesion  of 
the  posterior  columns  of  the  cord. 

In  unilateral  lesions,  the  side  opposite  to  the  site  of  the  lesion 
is  generally  the  site  of  a  disturbed  tactile  sense  (tactile  anesthesia), 
with  slight  hyperesthesia  on  the  side  with  the  lesion. 

Total  anesthesia  indicates  a  total  destruction  of  the  segment  of 
the  cord  at  that  level. 

In  estimating  the  extent  of  these  disturbances  it  must  always 
be  remembered  that  the  areas  of  skin  supplied  by  the  several  seg- 
ments of  the  cord  overlap. 

PAIN 

The  sensation  of  pain  may  be  referred  to  the  spine  itself  or  to 
any  situation  to  which  the  nerve  supply  goes.  Pain  referred  di- 
rectly to  the  spine  rather  more  indicates  irritation  of  the  posterior 
nerve  roots  or  the  meninges  than  of  the  cord  itself.  Pain  due  to 
lesions  in  the  cord  is  almost  invariably  referred  to  the  periphery 
below  the  level  of  the  lesion.  Thus  if  the  lesion  be  one  that  is 
situated  high  in  the  cord,  generalized  pain  may  be  the  result  over 
nearly  the  whole  of  the  body. 


VASOMOTOR   AND   TROPHIC    DISTURBANCES 

These  are  very  common  after  an  injury  of  the  cord  and  also  in 
certain  diseases.  Impaired  circulation,  with  a  consequent  blueness 
and  coldness,  is  commonly  encountered.  There  is  a  markedly  dimin- 
ished nutrition  of  the  tissues  and  therefore  they  are  rendered  much 
less  resistant  to  both  internal  and  external  influences.  Not  only  do 
the  muscles  suffer  in  their  nutrition  and  finally  atrophy,  but  the 
bones  may  also  become  fragile. 

When  it  is  recalled  that  this  faulty  nutrition  of  the  tissues  is 
accompanied  by  more  or  less  insensibility  to  pressure  and  to  pain, 
it  is  readily  observed  why  so  many  of  these  cases  suffer  from  gan- 
grenous lesions  and  bed-sores. 


268        NATURE  OF  INJURIES  OF  THE  SPINAL  CORD 
CHAPTER  XXXVI 

NATURE    OF   INJURIES    OF    THE    SPINAL    COED 

SPINAL  CONCUSSION 

Such  an  injury  to  the  cord  is  conceivable  when  the  force  which 
has  been  exerted  stops  short  of  real  contusion  and  experimentation 
shows  that  zonal  edema  of  the  ganglionic  cells  may  be  produced 
with  temporary  interference  with  normal  functioning.  The  symp- 
toms are  those  of  mental  shock  rather  than  those  of  any  definite 
pathological  condition.  At  one  time  this  supposed  injury  was 
responsible  for  extravagant  claims  for  damages.  The  protection 
which  is  naturally  afforded  by  the  body  to  the  spinal  cord  removes 
it  from  the  possibility  of  the  same  injury  as  might  more  easily  occur 
in  the  brain.  But  there  are  no  characteristic  symptoms  and  in 
human  beings  it  has  not  yet  been  definitely  demonstrated,  so  that 
we  may  dismiss  the  subject  from  further  consideration. 

CONTUSION  AND  LACERATION  OF  THE  CORD 

An  injury  of  this  character  will  usually  produce  a  partial  de- 
struction of  the  substance  of  the  cord  or  may  be  so  severe  as  to 
result  in  complete  destruction.  But  contusion  must  not  be  con- 
fused with  that  temporary  disability  from  a  possible  zonal  edema. 
Zonal  edema  acts  by  partial  separation  of  the  cells  by  effusion  and 
by  pressure ;  or,  in  other  words,  it  is  a  very  mild  degree  of  contusion 
without  any  destruction. 

Contusion  of  the  cord  does  not  usually  occur  without  a  very 
considerable  injury  to  the  tissues  which  surround  the  cord ;  in  fact, 
the  cord  suffers  less  proportionately.  There  may  be  a  total  absence 
of  symptoms  in  the  beginning  and  several  days  or  weeks  may  elapse 
before  the  usual  symptoms  of  gradual  complete  zonal  paralysis  are 
in  evidence.  At  best,  the  whole  symptomatology  is  uncertain  and 
in  no  way  characteristic. 


MODE    OF    PRODUCTION  269 

On  the  other  hand,  there  may  be  immediate  loss  of  motion  with 
a  much  blunted  or  lost  sensation. 

We  are  compelled  to  base  our  diagnosis  of  contusion  alone  upon 
a  marked  increase  in  the  sensitiveness  to  pressure  over  the  spine  at 
the  .level  of  the  injury  and  with  a  coincident  disturbance  of  the 
•nerves  below  that  level,  after  we  have  excluded  any  disturbance  of 
the  bony  parts.  To  be  successful  in  the  latter,  we  must  depend 
upon  a  most  painstaking  examination  and  radiography.  This  is 
an  important  differentiation  to  make,  because,  by  excluding  any 
bony  injury,  we  have  a  clear  contraindication  for  an  operative  pro- 
cedure, with  the  possible  exception  of  lumbar  puncture,  if  intradural 
hemorrhage  occurs. 

Hemorrhage  into  the  cord  is  a  regular  accompaniment  of  con- 
tusions of  much  severity  and  may  occur  even  without  discoverable 
injury  to  the  bony  parts.  The  blood  may  find  its  way  through 
several  segments  of  the  cord  and  more  commonly  extends  upward 
than  downward. 

The  symptoms  are  focal.  The  destruction  of  the  cord  varies 
with  the  extent  of  the  hemorrhage  and  in  some  instances  a  very  con- 
siderable portion  may  be  distended  with  clot.  Later  on  when  this 
absorbs  a  cavity  may  be  left.  Intradural  hemorrhage  is  not  an  indi- 
cation for  operative  interference  unless  it  is  of  such  an  extent  that 
pressure  symptoms  occur  and  in  such  instances  relief  may  com- 
monly be  obtained  by  lumbar  puncture.  This  may  be  repeated  as 
occasion  demands.  The  situation  is  different  however  when  the 
hemorrhage  is  into  the  cord  itself  (hematomyelia),  for  then  an 
early  operation  is  always  indicated.  The  demand  is  for  early  and 
immediate  control  before  extensive  separation  of  the  ganglionic 
cells.  Late  operative  interference  does  not  offer  much  relief  as  the 
destructive  element  is  soon  established. 


MODE  OF  PRODUCTION  OF  INJURIES  TO  THE  SPINAL 

CORD 

In  fractures  and  in  dislocations  it  is  not  unusual  for  the  bones 
to  become  displaced  in  such  a  manner  that  the  canal  is  suddenly 


270  LUMBAR  PUNCTURE 

narrowed,  so  that  the  cord  is  either  compressed,  torn  or  cut  across. 
The  tendency  is  then  for  the  bones  to  spring  immediately  back  to 
place  after  the  force  causing  the  injury  is  removed.  The  cord  may 
entirely  escape  injury  or  only  suffer  a  slight  contusion  even  when 
the  bone  injury  is  extensive. 


CHAPTER  XXXVII 

LUMBAE    PUNCTURE 

Lumbar  puncture  is  a  minor  surgical  procedure  and,  because 
it  is  so,  its  value  has  been  very  much  underestimated.  When  first 
introduced  by  Quincke  it  was  accepted  as  a  procedure  which  was 
replete  with  hidden  dangers,  because,  by  it,  there  was  an  invasion 
of  parts  which  were  heretofore  considered  impossible  of  such  attack. 
Now,  a  far  different  view  obtains  and  because  of  its  widespread 
application  within  the  few  years  following  its  introduction  it  has 
been  looked  upon  as  a  minor  operation  and  is  not  used  as  fre- 
quently or  as  efficiently  as  it  might  well  be.  Lumbar  puncture  in 
surgical  pediatric  practice  is  minor  only  in  its  technique.  It  is  ab- 
solutely necessary  that  the  surgeon  working  among  children  have  a 
clear  knowledge  of  its  technique  and  of  the  possibilities  of  diagnosis 
and  treatment  which  result  from  its  judicious  application. 

It  is  not  strange  that  there  should  at  first  have  been  a  hesitancy 
about  invading  the  subarachnoid  space,  and  that  the  anatomical 
relationships  of  the  cerebrospinal  axis  and  its  membranes,  coupled 
with  the  many  changes  which  the  cerebrospinal  fluid  might  undergo 
pathologically,  made  the  procedure  one  of  doubtful  utility.  But 
experience  has  proven  that  the  procedure  has  a  very  definite  value 
and  that  this  is  true  in  such  a  large  sense  that  its  use  should  be 
much  more  common  than  at  the  present  time,  for  commonly  by  its 
aid  uncertainty  gives  way  to  certainty,  and  apparently  correct  con- 
clusions arrived  at  clinically  are  changed  entirely  or  modified 
through  the  pathological  findings  made  possible  by  lumbar  puncture. 
We  will  first  consider  the  technique  of  the  operation. 


LUMBAR  PUNCTURE 


271 


The  instruments  necessary  for  the  proper  performance  of  this 
procedure  are  a  small  scalpel,  a  stylet  needle,  a  sterilized  graduated 
tube  hydrometer,  and  culture  tubes.  It  is  so  rarely  necessary  to 
estimate  the  pressure  of  the  fluid  in  children  that  a  manometer  is 
not  needed.  The  most  satisfactory  needle  is  one  that  is  fitted  with 
a  stylet  and  is  specially  devised  for  its  purpose.  However,  an 
ordinary  hypodermic  needle  has  been  used  successfully  many  times, 
but  its  danger  is  in  the  long  point  with  which  it  is  equipped.  When 
one  is  not  fully  prepared  with  the  proper  needle  it  is  much  better 
to  file  off  the  point  of  the  ordinary  hypodermic  needle  so  that  it  is 


FIG.  101. — CORRECT  POSTURE  FOR  PERFORMANCE  OF  LUMBAR  PUNCTURE. 
The  child  should  be  held  firmly  on  a  hard  surface,  so  that  there  is  no  marked  lateral  curve 
to  the  body  but  so  that  the  spine  is  arched  well  by  steady  pressure  of  the  hands  of 
the  assistant. 

almost  square  across,  rather  than  to  hesitate  about  performing  the 
procedure. 

The  scalpel  is  used  to  divide  the  skin  at  the  chosen  site,  so  that 
infection  shall  not  be  carried  into  the  canal  with  the  introduction 
of  the  needle.  The  skin  of  small  children  is  so  thin  that  we  do 
not  feel  that  the  use  of  the  scalpel  is  necessary  in  them,  but  only 
•in  those  who  have  unusually  thickened  skins  or  are  closely  approach- 
ing adult  life. 

The  location  of  the  puncture  should  be  between  either  the  third 
and  fourth  or  between  the  fourth  and  fifth  lumbar  vertebrae. 

We  have  found  that  the  sitting  position  in  children  is  imprac- 


272 


LUMBAR  PUNCTURE 


tical,  for  we  fail  to  secure  their  perfect  cooperation,  and  the  danger 
of  breaking  the  needle  is  always  present.  The  recumbent  posture 
upon  the  side  is  the  best  possible  one,  as  it  allows  of  the  most  per- 
fect control  of  the  possible  struggles  of  the  child.  In  this  position 
the  child's  knees  should  be  drawn  well  up  and  the  shoulders  brought 
forward,  thus  bending  the  body  forward  in  an  arch.  The  necessity 
of  having  the  child  lying  upon  a  firm  surface  will  be  readily  seen, 
so  that  there  can  be  no  marked  lateral  bending  of  the  back. 

To  locate  definitely  the  correct  lumbar  space  for  the  puncture 


FIG.  102. — LOCATING  THE  RIGHT  POINT  OF  ENTRANCE  IN  LUMBAR  PUNCTURE. 
A  tape  passed  taut  between  the  crests  of  the  ilium  crosses  the  space  between  the  fourth 
and  fifth  lumbar  vertebra?,  which  is  usual  point  of  entrance. 

an  imaginary  line  is  drawn  across  from  the  crest  of  one  ilium  to 
the  crest  of  the  other,  or  a  sterilized  tape  or  cord  may  be  stretched 
across  and  either  of  these  will  be  the  guide  for  the  point  of  puncture. 
The  needle  should  be  inserted  in  the  interspinous  space  just  below 
this  level. 

The  preparation  of  the  skin  should  be  most  carefully  attended 
to,  and,  although  the  procedure  is  so  simple  in  its  performance, 
every  precaution  should  be  taken  as  regards  strict  asepsis.  The 
skin  should  be  gently  cleansed  with  green  soap  and  finally  with 
alcohol,  and  after  this  is  done  the  exact  site  of  the  puncture  should 


273 


be  painted  lightly  with  tincture  of  iodin.  This  procedure  insures 
against  infection  in  children  even  without  the  use  of  the  scalpel  to 
divide  the  skin. 

Anesthesia  is  usually  unnecessary  and  the  individuality  of  each 
child  and  the  nature  and  stage  of  the  disease  present  will  determine 
whether  any  anesthesia  is  necessary,  and  will  also  indicate  whether 
it  be  a  local  or  a  general  one.  We  are  constantly  performing 
puncture  without  any  anesthetic  and  always  without  untoward 
results. 

The  technique  is  simple  in  children.     The  point  of  the  needle 


FIG.  103. — THE  NEEDLE  IN  POSITION  AND  THE  FLUID  BEING  COLLECTED  IN  A  STERILE 

TUBE. 

should  be  inserted  very  slightly  to  the  side  of  the  median  line  and 
also  well  toward  the  lower  part  of  the  intervertebral  space.  While 
the  needle  is  held  firmly  its  point  should  be  directed  very  slightly 
toward  the  median  line  and  slightly  upward.  A  fair  degree  of 
force  may  be  necessary  to  puncture  the  skin  and  underlying  tissues, 
i)ut  after  this  first  resistance  is  overcome  there  should  be  no  display 
of  force  by  the  operator.  A  sudden  cessation  of  all  resistance  is 
usually  the  first  indication  that  the  point  of  the  needle  has  entered 
the  canal,  and  this  is  immediately  followed  by  the  escape  of  the 
fluid;  usually  drop  by  drop.  While  each  child  differs  somewhat 
anatomically  from  its  brother,  it  is  well  to  recall  that  the  canal  is 


274 


LUMBAR  PUNCTURE 


in  most  instances  reached  when  the  needle  has  penetrated  to  the 
depth  of  one  inch.  The  withdrawal  of  the  stylet  allows  of  the 
ready  escape  of  the  fluid. 

"Dry  taps"  are  in  almost  every  instance  due  to  a  failure  to 
enter  the  canal.  It  is  sometimes  stated  that  some  tissue  may  occlude 
the  needle,  or  that  the  fluid  is  too  thick  to  flow.  In  regard  to  the 
former,  the  use  of  the  stylet  overcomes  that  difficulty.  The  latter 

claim  for  a  dry  tap  seems 
at  first  most  reasonable, 
but  we  have  encountered 
several  such  instances  in 
which,  without  disturbing 
the  needle  at  all,  an  exag- 
geration of  the  flexure  of 
the  spine,  .coupled  with 
forcible  bending  of  the 
head  upon  the  chest,  has 
immediately  started  the 
flow  of  the  fluid.  In  sev- 
eral hundreds  of  punctures 
we  have  never  had  a  so- 
called  dry  tap.  With  the 
opportunity  to  immedi- 
ately puncture  the  canal 
following  unsuccessful  at- 
tempts to  do  so,  we  feel 
more  and  more  convinced 
that  dry  taps  are  evidence 
of  a  failure  to  enter  the  canal.  In  fact,  the  only  absolute  assur- 
ance that  one  has  that  he  has  entered  the  canal  is  the  withdrawal 
of  some  of  its  contents. 

Even  when  the  pressure  of  the  fluid  is  practically  negative,  as 
may  occur  when  the  cerebral  portion  of  the  subarachnoid  space  is 
blocked  by  inflammatory  products  or  a  new  growth,  at  least  suffi- 
cient will  escape  to  show  that  the  canal  has  been  entered. 

It  is  possible  that  the  point  of  the  needle  may  wound  the  rich 


FIQ.  104. — THE  UPRIGHT  POSITION  FOB  LUMBAR 
PUNCTURE. 

This  position  may  be  used  in  older  children  but 
the  patient  is  never  under  as  complete  con- 
trol as  in  the  posture  illustrated  in  Fig.  101. 


275 

plexus  of  veins  beneath  the  dura  and  when  this  occurs  a  few  drops 
of  blood  will  escape  and  this  must  be  differentiated  from  a  real 
hemorrhagic  condition  of  the  fluid  itself.  The  fact  that  the  first 
few  drops  of  blood  are  immediately  followed  by  the  appearance  of 
a  clear  fluid  will  distinguish  this. 

For  examination  this  blood-stained  fluid  may  be  discarded  but 
the  amount  measured. 

The  amount  of  fluid  withdrawn  will,  of  course,  be  determined 


FIG.  105. — UPEIGHT  POSTURE  IN  LUMBAR  PUNCTURE;  NEEDLE  IN  PLACE  AND  FLUID 

FLOWING. 

by  the  purposes  for  which  it  is  taken.  For  diagnostic  purposes, 
from  five  to  ten  c.  c.  is  sufficient.  When,  however,  the  fluid  is 
withdrawn  to  relieve  intracranial  pressure,  the  amount  withdrawn 
must  be  the  smallest  quantity  which  will  actually  accomplish  the 
desired  result. 

The  wound  should  be  closed  with  adhesive  plaster  or  covered 
with  collodion. 

Normal  cerebrospinal  fluid  is  colorless  and  like  water  in  its 
clearness,  of  an  alkaline  reaction  and  with  a  specific  gravity  of  be- 
tween 1.003  and  1.007.  While  the  amount  has  never  been 


276  LUMBAR  PUNCTURE 

accurately  determined,  it  has  been  closely  estimated  as  being  be- 
tween three  and  five  drams  in  infants  and  from  four  to  twelve 
drams  in  older  children.  While  these  figures  are  a  variable  quan- 
tity, yet  they  give  us  a  little  idea  of  the  amounts  usually  present. 
Amounts  much  in  excess  of  these  should  be  considered  as  suspicious. 
The  fluid  is  continuously  under  a  double  pressure,  elastic  and 
hydrostatic,  and  these  two  are  so  adjusted  that,  under  normal  con- 
ditions, the  fluid  escapes  rather  slowly,  drop  by  drop  (about  40 
drops  per  minute). 

It  contains  but  little  albumin  (0.02  to  0.05  per  cent.),  some 
chlorids  (0.7  per  cent.),  glucose  and  another  copper-reducing  sub- 
stance, and  traces  of  urea.  The  other  substances  contained  do  not 
interest  us  surgically. 

Increased  pressure  is  brought  about  by  anything  which  increases 
the  volume  of  the  fluid,  so  that  it  is  commonly  observed  under  such 
conditions  as  the  various  inflammatory  diseases  of  the  cerebrospinal 
axis  or  the  membranes,  new  growths  within  the  brain  or  cord, 
hemorrhages  or  fractures  that  interfere  with  the  normal  drainage 
and  absorption  of  the  fluid,  hydrocephalus,  in  some  hydremic  states 
of  the  blood  and  the  various  general  toxemias  which  cause  meningeal 
irritation. 

It  is  only  possible  to  isolate  or  determine  the  specific  form  of 
infection  in  the  fluid  by  a  thorough  bacteriological  examination. 
Such  an  examination  adds  precision  to  the  differential  diagnosis. 
For  instance,  it  is  not  uncommon  for  meningitis  to  clinically  pur- 
sue its  entire  course  with  a  symptomatology  that  is  so  uncertain, 
or  is  so  obscured  by  the  symptoms  of  an  intercurrent  disease,  that 
a  more  certain  means  of  diagnosis  must  be  sought.  We  have  this 
means  in  lumbar  puncture.  It  is  not  alone  that  positive  findings 
are  conclusive,  but  there  is  a  certain  value  in  negative  findings 
when  they  persist  over  a  period  of  several  days.  As  a  means  of 
accurate  diagnosis  there  is  no  one  procedure  which  offers  so  much 
satisfaction  in  the  affections  of  the  cerebrospinal  axis  or  its  mem- 
branes. Lumbar  puncture  as  a  means  of  treatment  has  a  much 
less  important  office  to  perform  than  in  diagnosis.  Its  use  in  this 
field  is  quite  limited  in  childhood.  There  are,  however,  some  in- 


SYMPTOMS  277 

stances  in  which  distressing  symptoms  due  to  pressure  may  be  im- 
mediately relieved,  and,  under  those  conditions  in  which  we  know 
that  the  fluid  must  be  laden  with  microorganisms  or  toxins,  the  pro- 
cedure is  justified  upon  the  ground  of  surgical  expediency,  if  for 
no  other  reason. 

Lumbar  puncture  as  a  means  of  administering  antitoxin  sera 
requires  the  use  of  a  somewhat  larger  needle  than  for  puncture 
alone,  and  one  to  which  the  syringe  may  be  attached. 

The  sera  for  tetanus  and  for  cerebrospinal  meningitis  are  the 
ones  used  in  this  manner.  The  puncture  is  made  in  the  usual  site 
and  manner  and  as  much  of  the  cerebrospinal  fluid  as  possible  is 
withdrawn  to  be  immediately  followed  by  the  injection  of  tho 
warmed  serum,  slowly  introduced  through  the  same  needle. 


CHAPTEE  XXXVIII 

INJURIES    OF    THE    BRAIN    AND    ITS    MEMBRANES 

SYMPTOMS 

The  various  injuries  and  diseases  of  the  brain  are  responsible 
for  certain  symptoms  which  may  be  local  or  general,  or  an  ad- 
mixture of  both.  This  symptomatology  may  be  dependent  upon 
some  interference  with  the  functions  of  the  brain  as  a  whole  or  be 
confined  to  some  limited  portion  of  the  brain  tissue.  Occurring  in 
portions  of  the  brain  in  which  the  function  has  been  definitely 
located,  we  are  able  to  apply  the  appropriate  surgical  interference 
for  relief  because  we  are  furnished  with  a  more  or  less  definite 
clew  as  to  the  extent  and  location  of  the  lesion. 

But  such  definiteness  is  unusual  in  childhood,  for,  at  this  period 
of  life,  the  very  unstable  nervous  system  and  the  relatively  poor 
inhibitory  control  render  the  symptomatology  consequent  upon  in- 
jury to  the  central  nervous  system  much  more  complicated  than  in 
adults. 

The  symptoms  due  to  cerebral  shock  are  commonly  so  marked 


278      INJURIES  OF  THE  BRAIN  AND  ITS  MEMBRANES 

that  for  the  time  they  mask  those  which  are  due  to  compression, 
laceration,  or  contusion.  In  addition,  children  are  especially  prone 
to  the  various  infections  and,  as  there  is  a  tendency  toward  infec- 
tion in  brain  injuries,  there  is  often  added  a  new  chain  of  symptoms 
which  are  merged  with  the  preceding  ones  and  either  complicate  or 
dominate  those  of  the  original  lesion. 

It  is  only  under  those  few  instances  in  which  we  have  the  most 
definite  and  exact  knowledge  of  cerebral  localization  that  we  may 
reasonably  hope  to  correctly  interpret  the  symptoms.  And  even 
under  these  conditions  we  are  often  surprised  to  find  that  our  ability 
to  localize  the  lesion  quite  definitely  is  rendered  less  certain  by 
the  fact  that  certain  large  areas  of  the  brain  may  be  injured  with- 
out anything  more  being  present  than  the  most  uncertain  and  unin- 
telligible symptomatology. 

It  is  unnecessary  for  us  to  consider  cerebral  localization  in  this 
section,  as  this  is  a  study  by  itself. 

Without  going  into  unnecessary  detail,  the  general  signs  of 
brain  lesions  are :  unaccountable  vomiting  without  preceding  nausea, 
headache,  vertigo,  optic  neuritis,  convulsions,  stupor,  and  coma. 
The  focal  motor  symptoms  are  in  part  irritative  and,  in  part,  de- 
structive, so  that  we  may  have  various  muscular  contractions,  or 
paralysis,  and  these  may  assist  in  more  or  less  definitely  locating  the 
lesion. 

Even  in  the  face  of  a  history  of  a  definite  injury,  the  surgeon 
must  not  be  unmindful  of  the  fact  that  there  may  commonly  be  in 
children  associated  lesions,  and  that  the  act  of  vomiting  may  be 
centric,  toxemic,  or  reflex. 

Cerebral  Vomiting. — Cerebral  vomiting  is  always  sudden  and 
more  or  less  projectile  in  character  and  occurs  without  any  of  the 
evidences  of  preceding  nausea.  The  act  occurs  as  though  it  were 
the  contents  of  the  mouth  that  were  being  expelled  instead  of  those 
of  the  stomach.  This  may  occur  while  the  stomach  is  empty  and 
is  usually  aggravated  by  sudden  changes  of  position,  especially  from 
the  horizontal  to  the  vertical.  Persistency  is  its  chief  characteristic ; 
it  yields  to  no  treatment  or  diet  and  each  act  leaves  the  child  more 
and  more  prostrated  and  without  the  evident  sense  of  relief  that 


SYMPTOMS  279 

comes    by    expulsion    of    the    stomach    content    in    other    types    of 
vomiting. 

Headache. — It  is  true  in  a  measure  of  all  pains,  but  particularly 
of  headache,  in  children,  that  it  is  not  definitely  located  but  com- 
plaint is  made  in  a  general  way.  Headache  in  children  under  the 
age  of  five  years  is  uncommon  except  in  connection  with  disease  or 
injury  of  the  brain  or  its  membranes.  If  there  be  an  associated  ele- 
vation of  temperature  the  first  thing  that  must  be  determined  is  to 
what  extent  the  headache  is  dependent  upon  the  rise  of  tempera- 
ture. This  is  decided  by  considering  the  intensity  of  the  fever  and 
the  character  of  the  headache.  In  regard  to  the  intensity  of  the 
fever,  headache  is  rare  in  children  with  a  temperature  under  103° 
F.,  unless  there  is  disease  or  injury  of  the  brain  or  meninges,  and 
then  it  may  be  intense  even  with  a  low  or  normal  temperature.  The 
character  of  the  headache  is  such  when  due  to  rise  in  temperature 
that  it  is  readily  relieved  by  pressure  over  the  temples,  by  the  appli- 
cation of  cold  locally,  or  by  massage  of  the  veins  of  the  neck,  and 
is  increased  for  a  time  by  active  motion.  Persistent  headaches 
should  always  arouse  the  suspicion  of  cerebral  tumor  or  abscess. 

Convulsions. — It  must  be  remembered  that  the  very  young  infant 
is  comparatively  free  from  convulsive  seizures  even  from  extensive 
lesions,  because  of  the  immaturity  of  its  nervous  system.  But  from 
the  third  month  of  life  to  the  end  of  the  second  year  all  of  the 
nerve  centers  of  the  infant  are  most  irritable,  so  that  convulsions 
are  common.  Along  with  this  irritability,  there  exists  an  enfeebled 
inhibition,  so  that  there  is  only  a  mild  restraining  influence  exer- 
cised. 

Very  many  errors  have  been  made  in  ascribing  a  convulsion  to 
a  cerebral  cause  simply  because  it  happened  to  be  unilateral.  Such 
an  event  has  no  bearing  unless  the  unilateral  convulsions  are  con- 
tinued over  a  protracted  period.  It  cannot  be  too  emphatically 
stated  that  unilateral  convulsions  occur  without  the  slightest  evi- 
dences of  cerebral  disease. 

It  is  necessary  to  remember  in  the  diagnosis  of  convulsions  of 
a  cerebral  origin  that : 

(a)   Convulsions    are   not    commonly    the    beginning    of    brain 


280      IN JUKIES  OF  THE  BRAIN  AND  ITS  MEMBRANES 

lesions,  but  are  of  later  occurrence.  For  instance  in  an  acnte  brain 
disease,  or  an  injury,  there  are  in  practically  every  instance  head- 
ache, somnolence,  retarded  and  irregular  pulse,  mental  dulness, 
etc.,  existing  before  the  onset  of  convulsions,  although  it  may  re- 
quire a  carefully  taken  history  to  bring  this  out,  as  the  convulsion 
seems  to  overshadow  every  other  event. 

(b)  Persistent  recurrences  are  the  rule.  It  is  easy  to  see  how 
shock,  fright,  or  any  one  of  the  many  influences  to  which  an  injured 
child  is  liable  might  act  reflexly  to  excite  a  single  convulsion,  but 
these  would  be  practically  coincident  with  the  infliction  of  the  in- 
jury and  would  not  persist. 

Paralysis. — Paralysis  due  to  a  cerebral  origin  is  chiefly  char- 
acterized by  a  spastic  condition  of  the  musculature  affected  by 
hemiplegia,  exaggerated  reflexes,  and  no  change  in  electrical  re- 
actions. As  a  remote  feature  there  is  little  or  no  atrophy  of  the 
muscles  affected  by  the  paralysis. 

Muscular  Contraction. — It  is  important  to  differentiate  between 
a  true  spasticity  of  a  muscle  and  the  contracture  which  is  observed 
after  degeneration  of  a  muscle,  as  is  frequently  seen  during  child- 
hood. In  the  latter  condition  there  is  a  permanent  flexion,  and 
the  resistance  to  passive  motion  is  not  because  of  an  increased  mus- 
cular tone,  but  is  dependent  upon  actual  change  in  the  structure 
of  the  muscle  itself. 

As  the  observance  of  the  condition  of  the  musculature  is  so  very 
important,  it  may  be  well  to  define  briefly  what  is  meant  by  mus- 
cular tone.  Muscular  tone  means  that  condition  of  the  voluntary 
muscles  by  which  there  is  always  maintained  a  sufficient  degree  of 
tension  to  enable  the  muscle  promptly  to  respond  to  nerve  stimula- 
tion. Naturally  this  tone  varies  under  normal  conditions,  but 
only  to  a  slight  degree.  Under  the  influence  of  fatigue,  ane- 
mia, malnutrition,  or  any  condition  which  tends  to  permanently 
or  temporarily  exhaust  the  system  (and  therefore  during  shock) 
there  is  a  lessened  tone.  The  most  satisfactory  test  of  muscular 
tone  is  the  resistance  offered  to  passive  motion.  The  limb  is  grasped 
firmly  and  suddenly  flexed,  and,  if  the  normal  tone  exists,  there  is 
a  very  transient  involuntary  resistance,  which  rapidly  disappears, 


COXCUSSIOtf    OF    THE    BRAIN  281 

so  that  the  limb  may  be  freely  moved  with  but  slight  effort.     The 
child  must  be  off  its  guard  when  this  procedure  is  undertaken. 

By  assuming  to  make  the  desired  motion,  as  if  in  play,  so  as 
to  gain  the  child's  confidence,  and  then  suddenly  diverting  its  atten- 
tion, the  test  can  be  satisfactorily  made,  even  in  rebellious  patients. 


CONCUSSION  OF  THE  BRAIN 

Concussion  of  the  brain  has  little  in  common  with  that  doubt- 
ful condition  of  spinal  concussion,  nor  can  the  arguments  against 
the  production  of  the  latter  be  reasonably  used  against  concussion 
of  the  brain  as  a  more  or  less  distinct  entity. 

By  cerebral  concussion  we  mean  the  condition  of  the  child  which 
follows  generalized  injury  to  the  head  in  which  there  is  no  lesion 
of  the  brain  that  can  be  recognized,  but  in  which  there  are  exhibited 
the  symptoms  of  temporary  impairment  or  loss  of  function  of  the 
brain  as  a  whole. 

Symptoms. — The  symptomatology  is  of  course  immediate.  Al- 
most coincident  with  the  infliction  of  the  injury  the  child  becomes 
unconscious.  This  unconsciousness  may  be  partial  or  complete, 
momentary  or  prolonged.  In  the  mild  cases  recovery  commences 
almost  immediately  and,  with  the  possible  exception  of  a  sense  of 
weakness,  slight  vertigo,  or  headache,  normal  consciousness  is  not 
further  disturbed.  However,  even  in  these  milder  instances  of  dis- 
turbance it  is  a  fact  that  the  child  is  incapable  of  accurately  de- 
scribing the  events  that  immediately  preceded  or  followed  the  in- 
fliction of  the  injury.  In  the  more  severe  instances  the  unconscious- 
ness may  last  for  several  hours  and  have  the  added  symptoms  of 
shock.  The  skin  is  pale,  the  pulse  slow  and  feeble,  the  respirations 
superficial  or  stertorous,  the  conjunctiva  insensitive,  and,  in  addi- 
tion, vomiting  and  muscular  twitchings  are  common. 

There  is  a  gradual  return  to  the  normal  after  several  hours,  as 
a  rule,  but  in  a  few  instances  such  symptoms  persist  for  a  day  with- 
out much  improvement.  The  child  generally  rebels  against  any 
attempts  at  interference  and  assumes  the  flexed  posture  on  the  side. 


282 

Prognosis. — An  increased  irritability  is  usually  a  favorable  sign, 
indicating  that  recovery  is  taking  place,  and  this  is  particularly  so 
if  accompanied  by  flushing  of  the  face  and  a  pulse  of  high  tension 
and  rapid. 

Diagnosis. — It  is  the  quite  rapid  and  steady  return  to  full  con- 
sciousness that  makes  the  diagnosis  possible.  Even  if  the  return 
to  consciousness  is  apparently  rapid  in  an  injured  child,  but  is  un- 
steady and  interrupted  with  periods  during  which  there  occurs  an 
undoubted  relapse,  we  must  be  suspicious  of  more  severe  injury 
than  concussion.  Or,  when  the  unconsciousness  is  prolonged  over 
a  period  of  twelve  hours,  it  is  then  more  than  probable  that  either 
contusion  or  laceration  is  present  in  some  degree. 

Treatment. — The  treatment  is  the  securing  of  absolute  mental 
and  physical  quiet  and  rest  until  consciousness  is  fully  restored. 


COMPRESSION   OF  THE  BRAIN 

Compression  of  the  brain  may  be  caused  by  any  condition  that 
creates  a  sudden  continuous  increase  of  intracranial  pressure  and 
therefore  may  be  dependent  upon  depressed  fragments  of  bone, 
foreign  bodies,  effused  blood,  or  inflammatory  exudates. 

Symptoms. — It  is  almost  impossible  during  the  first  few  hours 
after  an  injury  to  distinguish  between  the  symptoms  due  to  con- 
cussion and  those  due  to  compression.  This  is  true,  in  part,  be- 
cause the  two  are  usually  associated  and  it  is  only  when  the  symp- 
toms of  concussion  have  had  an  opportunity  to  clear  up  that  we  are 
able  to  clearly  distinguish  those  which  are  dependent  upon  the  com- 
pression. There  are  really  two  types  of  symptoms:  those  due  to 
irritation  and  those  due  to  direct  or  indirect  pressure. 

The  first  (the  irritative)  are  immediate  and  are  generally  evi- 
denced as  an  undue  excitability,  accompanied  by  marked  flushing 
of  the  face  and  a  slow  but  high-tension  pulse.  Nausea  and  vomit- 
ing are  common  and  the  fact  that  nausea  accompanies  this  type  of 
cerebral  vomiting  should  at  once  suggest  the  existence  of  irritation. 
The  sensorium  is  disturbed;  the  mentality  is  dulled  and,  while  the 


COMPRESSION    OF    THE    BRAIN  283 

child  continues  to  be  excessively  irritable,  the  mental  dulness  in- 
creases progressively  until  coma  supervenes. 

The  second  type  (the  pressure)  of  symptoms  set  in  with  tho 
onset  of  the  coma  and  this  event  really  marks  the  onset  of  the  true 
symptoms  of  compression.  The  change  in  the  pulse  is  marked,  the 
force  being  greatly  reduced  at  the  same  time  that  the  rate  is  pro- 
gressively diminished.  The  respirations  are  slow  and  may  become 
stertorous,  but  are  always  irregular. 

Perhaps  the  most  characteristic  symptoms  are  those  which  are 
observed  in  the  pupils.  The  pupil  upon  the  side  corresponding  with 
the  injury  is  at  first  contracted  and  very  shortly  after  becomes 
more  or  less  persistently  dilated,  so  that  there  is  always  a  consider- 
able difference  between  the  two  pupils.  Strabismus  is  not  uncom- 
mon and  may  be  associated  with  nystagmus,  which  latter  is  prac- 
tically always  present. 

Paralysis,  limited  to  groups  of  muscles,  is  not  infrequent  or 
there  may  exist  a  hemiplegia  or  paraplegia.  The  paralyses  when 
present  are  upon  the  side  opposite  to  the  compression. 

The  severity  of  the  compression  is  indicated  by  the  extent  of 
the  paralysis  and  the  degree  of  inequality  or  insensitiveness  of  the 
pupils. 

Paralysis  confined  to  groups  of  muscles,  which  do  not  cover  a 
large  area,  indicates  that  pressure  (probably  from  hemorrhage)  is 
situated  between  the  dura  and  the  skull  and  is  small  in  its  extent. 
Widespread  paralysis,  particularly  hemiplegia  or  paraplegia,  indi- 
cates a  very  considerable  injury  with  hemorrhage  beneath  the  dura. 

Prognosis. — There  is  one  very  constant  indicator  of  the  prognosis 
in  any  given  case  and  that  is  the  respiration.  Without  paying  too 
much  attention  to  the  nature  or  extent  of  the  injury,  the  surgeon 
has  this  clear  indication — that  the  farther  the  respirations  get  from 
the  normal,  both  as  regards  their  type  and  rhythm,  the  graver  the 
prognosis.  A  rapidly  fatal  issue  can  be  reasonably  expected  by  a 
type  of  respiration  which  exhibits  more  or  less  prolonged  cessation 
with  subsequent  irregular  resumption.  The  pulse  is  no  indicator 
in  children  of  either  the  severity  of  the  compression  or  its  probable 
outcome. 


284  THROMBOSIS  OF  THE  SINUSES 

CONTUSION,  LACERATION,  AND  WOUNDS  OF  THE  BRAIN 

The  substance  of  the  brain  may  be  contused  or  lacerated  as  the 
result  of  direct  or  indirect  violence  acting  upon  the  skull  or  the 
brain  itself.  We  may  therefore  have  lesions  which  vary  greatly; 
from  minute  punctate  hemorrhages  up  to  more  or  less  complete 
disorganization  of  a  large  or  even  a  greater  part  of  the  brain.  The 
injury  to  the  brain  does  not  depend  upon  the  situation  of  the 
violence,  for  it  is  not  uncommon  to  find  that  immediately  about 
the  point  of  greatest  violence  the  brain  is  practically  or  wholly 
uninjured,  while  distant  portions  on  the  same  or  even  the  opposite 
side  of  the  brain  may  exhibit  most  serious  disorganization. 

Symptoms. — The  symptoms  depend  very  largely  upon  the  por- 
tion of  the  brain  that  is  injured,  therefore  will  vary  greatly  in  any 
given  case.  However,  there  are  at  first  always  present  the  symp- 
toms of  cerebral  concussion  and  these  are  generally  associated  with 
those  due  to  intracranial  hemorrhage  and  compression.  Such  symp- 
toms may  be  very  severe,  but,  upon  the  other  hand,  there  may  be 
a  most  serious  injury  to  the  brain  without  any  immediate  definite 
symptoms.  Or  symptoms  may  not  be  in  evidence  at  all  until  sev- 
eral days,  weeks,  or  even  months  after  the  injury. 

Diagnosis. — The  only  way  in  which  a  diagnosis  can  be  reason- 
ably made  is  by  the  exclusion  of  concussion  and  compression  symp- 
toms and  this  may  require  the  assistance  of  the  X-ray  or  even  of 
operative  procedure. 

As  a  remote  effect,  epilepsy  is  not  uncommon. 


CHAPTER  XXXIX 

THEOMBOSIS    OF    THE    SINUSES    OF    THE    DURA    MATER 

While  there  are  two  types  of  sinus  thrombosis  which  occur  in 
children,  there  is  but  one  that  interests  the  surgeon,  and  that  is  the 
inflammatory.  The  other  type,  the  cachectic,  is  practically  impos- 


SYMPTOMS  285 

Bible  of  diagnosis  during  life  and  has  no  relation  to  the  surgical 
conditions  of  childhood  and  therefore  will  not  be  considered  here. 

Inflammatory  sinus  thrombosis,  which  is  also  commonly  known 
as  septic  thrombosis  and  sinus  phlebitis,  occurs  most  commonly  in 
connection  with  meningitis,  but,  as  a  surgical  complication,  its 
most  common  occurrence  is  with  the  infectious  processes  affecting 
the  middle  ear.  While  this  is  true  in  a  general  way,  it  ought  to 
be  emphasized  that  its  association  in  this  particular  is  less  common 
during  childhood  than  in  adult  life. 

Etiology. — It  may  have  as  its  etiology  traumatism  about  the 
head,  necrosis  of  the  cranial  bones,  or  infectious  processes  affecting 
any  of  the  soft  parts  of  the  face  or  head,  or  similar  processes  of 
the  mouth,  nasal  fossa,  or  pharynx.  The  acute  infectious  diseases, 
such  as  scarlet  fever  and  diphtheria  in  particular,  make  infection 
easy  through  the  mouth  and  the  pharynx. 

Site. — The  site  of  the  original  disease  determines  the  site  of 
the  thrombosis.  Thus,  if  the  primary  infection  is  of  the  cranial 
bone,  or  of  the  scalp,  extension  is  to  the  longitudinal  sinus;  if  of 
the  ear,  then  the  lateral  sinus;  if  the  base  of  the  skull,  the  mouth, 
the  jaw,  or  the  nose,  then  the  cavernous  sinus. 

Symptoms. — The  GENERAL  SYMPTOMS  are  those  of  pyemia  (un- 
less occurring  in  the  course  of  meningitis,  when  practically  no  new 
symptoms  are  added).  The  symptomatology,  therefore,  is  usually 
that  of  recurring  chills  (or  convulsions  in  the  very  young),  asso- 
ciated with  a  widely  fluctuating  but  usually  very  high  temperature 
and  considerable  sweating.  It  is  just  such  symptoms  associated 
with  some  primary  infectious  process  about  the  head  or  face  that 
•suggest  the  diagnosis  and  if  in  an  infant  we  observe  the  symp- 
toms and  local  signs  of  an  infection,  followed  by  convulsions  and 
somnolence,  it  should  at  once  excite  the  suspicion  of  sinus  throm- 
bosis. Headache  may  be  present  in  a  minor  degree  and  if  it  is 
persistent  or  severe,  or  becomes  associated  with  marked  vomiting, 
it  indicates  a  complicating  meningitis.  In  fact,  the  cerebral  symp- 
toms are  far  from  being  characteristic,  consisting  usually  of  mild 
headache,  crying  out  during  the  sleep,  somnolence,  and  possibly 
coma.  Or  added  to  these  there  may  be  strabismus,  nystagmus,  and 


286  THROMBOSIS  OF  THE  SINUSES 

dilatation  of  the  pupils.  Very  rarely  we  may  observe  paralysis. 
Metastasis  is  not  uncommon  and  in  some  instances  there  are  evi- 
dences of  abscesses  of  the  brain  or  other  organs,  and,  more  rarely, 
an  extension  into  the  internal  jugular  vein,  so  that  that  vessel  may 
be  easily  felt  as  a  hard  cord  just  along  the  anterior  border  of  the 
sternomastoid  muscle. 

The  LOCAL  SYMPTOMS  are  dependent  largely  upon  the  particular 
sinus  affected. 

Cyanosis  of  the  face,  with  dilatation  of  the  temporal  and  frontal 
veins,  with  or  without  epistaxis,  indicates  an  infection  of  the 
superior  longitudinal  sinus. 

Dilatation  of  the  veins  of  the  neck,  or  the  hardening  of  the  in- 
ternal jugular  vein,  as  already  referred  to,  with  or  without  edema 
behind  the  mastoid  process  and  possible  extension  to  the  neck,  sug- 
gests an  invasion  of  the  lateral  sinus. 

Not  uncommonly  attention  is  first  directed  to  the  infection  by 
the  objective  evidences  of  pain  whenever  the  head  is  moved.  The 
child  therefore  attempts  to  limit  such  motion  and  there  consequently 
often  exists  a  persistent  lateral  inclination  of  the  head  and  this  is 
accompanied  with  more  or  less  dysphagia. 

Protrusion  of  the  eyeball  of  the  affected  side,  or  localized  edema 
about  the  orbit,  indicates  the  cavernous  sinus  as  the  site  of  the  in- 
fection. One  or  both  sides  may  be  affected. 

It  must  be  readily  observed  that  these  local  signs  are  all  very 
uncertain  and  that  but  little  reliance  can  be  placed  upon  them 
alone  as  a  means  of  diagnosis.  It  is  only  by  their  close  association 
with  a  more  definite  general  symptomatology  that  they  have  any 
value  and  they  must  be  considered  in  that  relationship. 

Course  and  Prognosis. — The  course  of  the  infection  is  very  irregu- 
lar and  uncertain  and  may  cover  a  period  of  a  very  few  days  or 
persist  for  three  weeks  or  more.  The  prognosis  is  always  grave, 
death  usually  taking  place  from  meningitis,  cerebral  abscess,  pyemia, 
or  a  rapid  exhaustion.  Of  course,  there  always  remains  the  pos- 
sibility of  a  collateral  circulation  being  established,  or  of  an  oblitera- 
tion of  the  sinus  by  fibrous  tissue  and  a  secondary  hydrocephalus, 
but  even  this  means  temporary  relief  only. 


ETIOLOGY  287 

Treatment. — The  treatment  is  purely  surgical  and  the  results 
depend  almost  entirely  upon  the  accessibility  of  the  infection. 
Operations  upon  the  lateral  sinus  offer  the  most  promising  results 
and,  whenever  the  diagnosis  is  clear,  operative  procedure  should  be 
immediate. 


CHAPTER  XL 


Abscess  of  the  brain  is  a  much  more  frequent  disease  during 
childhood  than  is  ordinarily  supposed.  The  difficulty  surrounding 
its  diagnosis  has  often  resulted  in  its  being  overlooked.  Its  most 
common  occurrence  during  childhood  is  between  the  ages  of  five 
and  ten  years,  it  being  a  rarity  either  before  or  after  that  period, 
until  well  into  adult  life.  Before  the  beginning  of  the  fifth  year 
of  life  the  marked  tendency  is  toward  suppurative  meningitis 
rather  than  abscess. 

Etiology. — The  etiology  is  two-fold  in  the  main :  otitis  and 
trauma.  By  far  the  most  frequent  cause  is  a  chronic  otitis.  And 
chronicity  seems  to  be  a  most  important  factor,  for  it  is  rarely  the 
case  that  an  acute  otitis  is  followed  by  brain  abscess,  so  that,  while 
we  remain  uncertain  as  to  the  exact  manner  in  which  a  chronic  otitis 
results  in  abscess,  we  must  always  bear  in  mind  its  relatively  great 
influence  as  the  etiological  factor.  It  is  not  necessary  that  the  pus 
be  retained  for  the  production  of  cerebral  abscess;  as  many  cases 
occur  when  the  discharge  is  free  as  when  it  is  not. 

Trauma  is  another  important  eiological  factor  and  the  degree  or 
extent  of  the  injury  need  not  be  great.  Even  in  the  instances  in 
which  cerebral  concussion  has  been  diagnosed  abscess  may  follow, 
but  in  such  instances  there  was  probably  some  undiscoverable  con- 
tusion or  laceration  present  also.  In  some  cases  it  is  impossible  to 
reasonably  assign  the  cause. 

The  abscess  is  the  result  of  an  acute  inflammation  of  the  brain. 
The  center  of  the  diseased  focus  breaks  down  and  suppurates  rapidly 


288  CEREBRAL  ABSCESS 

and  the  resulting  cavity  is  filled  with  the  necrotic  material,  a  yellow- 
ish green,  fetid  pus,  fluid,  and  bacteria.  In  addition  to  the  pus- 
producing  organisms  there  may  be  present  also  other  pathogenic 
bacteria,  as  the  pneumococcus  or  tubercle  bacillus.  Within  a  few 
weeks  the  cavity  may  become  encapsulated  and  assume  a  more 
regular  spherical  shape.  But  encapsulation  does  not  in  any  way 
indicate  a  cure  although  it  may  cause  the  abscess  to  remain  latent 
for  a  long  period  (perhaps  years). 

Traumatic  abscess  is  practically  always  solitary  and  its  most 
common  situation  is  the  cerebrum. 

Otitic  brain  abscess  follows  a  morbid  process  which  begins  in 
the  bone  and  only  involves  the  dura  secondarily.  The  usual  situa- 
tion is  in  the  temporal  lobe  or  in  the  cerebellum. 

Symptoms. — The  symptomatology  is  influenced  by  many  factors, 
chief  of  which  are  the  site  of  the  abscess  and  the  stage  of  the 
disease. 

In  regard  to  the  latter,  we  can  more  or  less  clearly  distinguish 
four  rather  well-defined  stages: 

(1)  The  initial  stage,  which  may  be  ushered  in  by  a  train  of 
symptoms  which  are  so  slight  as  to  pass  unnoticed  or  be  assigned 
to  some   slight  indisposition.      In   other  instances   these   symptoms 
may  be  masked  by  those  of  the  primary  disease  or  the  injury.     But 
when  present  so  as  to  be  appreciated,  they  are  headache,  vomiting, 
chills,  and  a  general  prostration.     Such  symptoms  are  common  to 
many  other  conditions  in  childhood,  so  that  it  is  rather  their  asso- 
ciation with  possible  causative  factors  of  cerebral  abscess  that  gives 
them  value.     The  initial  stage  lasts  for  from  one  to  five  or  six  days 
and  is  merged  into  the  next  stage. 

(2)  The  latent  stage.     This  may  be  entirely  absent  or  be  so 
short  that  it  is  practically  impossible  to  distinguish  it.     However, 
the  usual  course  is  for  this  latent  stage  to  persist  over  a  long  period 
so  that  for  months  there  may  be  an  almost  entire  absence  of  symp- 
toms.     With  the   possible   exceptions   of   an    occasional    headache, 
vertigo,    or   nausea,    and,    more   rarely,    chilliness    and   drowsiness, 
there  may  be  nothing  to  interrupt  the  latent  stage.     A  few  reported 
cases  have  shown  that  this  stage  may  persist  for  several  years.     If 


SYMPTOMS  289 

focal   symptoms   have  been  present   during  the   initial   stage  they 
still  persist  in  the  latent  stage  but  they  do  not  progress. 

It  is  easy  to  see  how  a  prolonged  latent  stage  would  cause  one 
to  forget  the  symptoms  of  the  initial  stage,  or  to  assign  them  to 
some  other  cause,  and,  therefore,  in  the  taking  of  the  history  this 
point  should  be  recalled. 

(3)  The  stage  of  full  development.     This  in  a  few  instances 
seems  to  immediately  follow  the  initial  stage,  but,  as  has  been  sug- 
gested, the  latent  stage  may  intervene.     The  general  symptoms  of 
the  initial  stage  are  still  present,  but  there  are  added  to  these  those 
symptoms  which  depend  upon  the  situation  of  the  lesion  and  its 
size.     The  usual  course  is  for  the  headache  to  become  less  intense 
but  more  definitely  located,  and  its  intensity  is  influenced  greatly 
by  anything  which  raises  the  blood  pressure.     Percussion  may,  at 
times,  reveal  localized  pain  in  the  skull.     When  vomiting  is  present, 
a  sudden  change  of  posture  usually  provokes  it.     Convulsions  are 
not  common. 

The  pulse  rate  is  markedly  reduced,  so  that  it  is  not  uncommon 
to  note  a  fall  to  40  or  50  beats  a  minute,  and  the  rate  is  out  of  all 
proportion  to  the  respirations,  which  remain  unchanged,  with  one 
exception:  in  cerebellar  abscess  they  are  also  reduced.  The  tem- 
perature remains  normal  or  subnormal,  as  a  rule,  but  there  may 
occur  slight  rises.  When  such  a  rise  occurs,  it  is  always  slight  and 
characteristically  persistent.  A  high  temperature  or  a  fluctuating 
one  should  arouse  suspicions  of  suppurative  meningitis  or  sinus 
thrombosis,  for  it  is  not  suggestive  of  an  uncomplicated  cerebral 
abscess. 

Psychic  changes  are  merely  suggestive  and,  while  they  have  a  cer- 
tain interest,  they  are  not  real  aids  to  diagnosis.  They  consist  in 
the  main  of  lapses  of  memory,  periods  of  excitability,  facial  flush- 
ings, etc. 

Occasionally  this  stage  of  full  development  is  apparently  ab- 
sent because  the  terminal  stage  is  ushered  in  with  great  rapidity, 
so  that,  like  lightning  out  of  a  clear  sky,  acute  symptoms  develop 
and  prove  rapidly  fatal. 

(4)  The  terminal  stage.     This  is  usually  merged  with  the  pre- 


290  CEREBRAL  ABSCESS 

ceding  stage,  so  that  there  is  no  clear  line  of  demarcation  between 
the  two,  but  merely  the  increased  evidences  of  progression.  It  has 
already  been  mentioned  that  the  intervening  stages  may  be  so  short 
that  the  terminal  stage  seems  to  immediately  follow  the  initial  stage, 
or,  more  often,  the  latent  stage. 

The  symptomatology  of  this  stage  is  dependent  upon  a  rapid  ex- 
tension of  the  inflammatory  process  associated  with  an  edema  and 
softening  of  the  tissues  about  the  abscess,  to  the  rupture  of  the 
abscess,  or  a.  supervening  meningitis.  Thus,  we  may  observe  a 
great  variety  of  symptoms  but  it  is  always  a  more  intense  symptoma- 
tology than  has  immediately  preceded.  There  is,  however,  one  ex- 
ception to  this,  and  that  is  when  the  symptoms  preceding  the 
terminal  stage  are  not  intensified  but  modified  and  even  made  less 
active  by  the  onset  of  the  marked  symptoms  of  pyemia  and  rapid 
and  extreme  exhaustion  without  any  well-defined  cerebral  symptoms. 

The  focal  symptoms  are  generally  very  indefinite,  for  an  abscess 
of  a  considerable  size  may  be  present  in  the  temperosphenoidal 
lobe  for  instance,  in  the  central  portion  of  the  frontal  lobe,  or  in 
the  cerebellum  without  appreciable  focal  signs.  It  is  only  in  a  few 
favored  instances  that  we  are  able  to  locate  the  abscess  definitely 
from  the  focal  signs. 

Word  deafness  (hearing  but  not  understanding  the  spoken  word), 
deafness  upon  the  opposite  side,  and  oculomotor  paralysis  would 
suggest  an  affection  of  the  temporal  lobe.  Cortical  convulsions  and 
opposite-sided  hemiplegia  would  suggest  the  parietal  lobe. 

Rigidity  of  the  neck  musculature,  interference  with  the  gait, 
violent  headache,  and  vomiting  suggest  the  cerebellum  as  the  site. 
Persistently  indefinite  focal  signs  are  the  rule,  particularly  if  the 
frontal  lobe  be  affected. 

Occipital  lobe  abscess  is  rare. 

Difficult  as  it  may  be  to  satisfactorily  establish  it,  it  should 
constantly  be  our  effort  to  determine  the  exciting  cause,  whenever 
we  are  suspicious  of  cerebral  abscess.  We  must  also  be  cognizant 
of  the  fact  that,  in  children,  disease  of  the  nose  or  ear  may  remain 
apparently  latent  for  a  very  long  period,  and  that  injury  to  the 
head  may  not  immediately  be  followed  by  symptoms  due  to  conse- 


quent  disease.  The  very  indefiniteness  of  the  symptomatology 
should  be  remembered,  despite  the  fact  that  a  considerable  amount 
of  suppuration  may  be  present  in  the  brain. 

And  even  in  those  instances  in  which  we  are  quite  positive 
of  intracranial  suppuration  we  must  differentiate  suppurative 
meningitis  and  sinus  thrombosis  from  brain  abscess.  Suppurative 
meningitis  has  a  much  more  acute  onset  than  has  abscess,  and  the 
symptomatology  is  always  more  acute  and  progressive  from  the 
very  beginning.  However,  with  all  this  common  acuteness  and 
rapid  progression,  the  local  symptoms  are  more  unreliable  and 
transitory.  Lumbar  puncture  reveals  the  presence  of  pus. 

Sinus  thrombosis  exhibits  a  rather  typical  pus  temperature,  with 
possible  chills,  and  sweating  and  local  edemas  are  common  occur- 
rences. In  both  instances,  the  history  of  the  onset  and  the  considera- 
tion of  the  events  which  immediately  and  remotely  preceded  it  will 
serve  to  distinguish  each  disease  in  a  much  more  certain  manner 
than  will  the  particular  attention  to  individual  or  special  symptoms. 
A  study  of  the  previous  history  of  the  child  is  therefore  of  much 
more  importance  than  the  mere  study  of  the  symptomatology. 

Diagnosis. — The  diagnosis  of  chronic  abscess  from  tumor  is  not 
always  simple.  In  tuberculous  children  particularly,  the  association 
of  brain  tubercle  with  a  chronic  and  persistent  discharge  from  one 
or  from  both  ears  is  not  uncommon  and  this  may  easily  prove  mis- 
leading if  the  discharge  from  the  ear  is  considered  as  the  primary 
disease. 

The  main  points  to  consider  are  these:  tumor  may  occur  at  any 
age  and  without  a  definite  etiology  (with  the  one  exception  of 
tubercle),  and  is  also  characterized  by  its  slow  but  very  persistent 
course,  with  the  constant  addition  of  newer  symptoms  as  the  older 
ones  progress.  Violent  and  persistent  headache  is  a  prominent 
feature,  mental  disturbances  are  marked,  focal  symptoms  are  quite 
definite,  and  fever  is  absent.  In  contradistinction  to  this,  cerebral 
abscess  is  rare  before  five  years  or  after  ten  years  in  children,  it 
presents  a  definite  history  or  etiology  if  this  be  carefully  sought, 
it  exhibits  a  most  irregular  course  both  as  regards  the  symptoms 
and  the  various  stages  of  the  disease  and  their  relationship  to  each 


292  INTEACRAN1AL   TUMORS 

other,  headache  is  not  one  of  the  characteristic  symptoms,  and  focal 
symptoms  are  indefinite. 

However,  despite  all  these  differences,  it  is  not  always  possible 
to  avoid  a  reasonable  error  in  the  diagnosis,  or,  at  best,  we  may 
be  compelled  to  remain  for  a  time  in  doubt  as  to  the  real  nature 
of  the  lesion.  In  such  instances  it  is  good  judgment  to  consider 
the  case  as  one  of  abscess  and,  if  possible,  to  give  the  child  the 
benefit  of  operative  interference. 

Prognosis. — The  prognosis  is  very  unfavorable.  Not  infre- 
quently rupture  supervenes  before  the  symptoms  have  given  suffi- 
cient warning  of  the  progress  of  the  disease. 

Treatment. — Medical  treatment  of  cerebral  abscess  offers  nothing 
more  than  the  temporary  relief  which  might  come  from  the  usual 
measures  used  in  the  acute  stage  of  acute  intracranial  inflammation. 
The  utter  hopelessness  of  any  permanent  relief  coming  from  any- 
thing else  but  surgical  interference  should  lead  to  the  earliest  pos- 
sible operative  relief. 


INTRACEANIAL    TUMORS 

In  a  study  of  the  neoplasms  which  affect  the  central  nervous  sys- 
tem, we  are  at  once  confronted  with  the  fact  that  the  nature  of 
the  neoplasm  has  much  less  to  do  with  the  symptomatology  than 
has  the  site  of  the  tumor.  Thus  it  would  seem  to  us  reasonable  to 
consider  intracranial  tumors  in  a  somewhat  different  manner  from 
other  growths  and  give  little  attention  to  the  exact  nature  of  the 
lesion. 

Intracranial  tumors  are  not  uncommon  during  childhood,  al- 
though they  may  be  considered  as  rare  under  the  age  of  two  years, 
with  the  one  exception  of  tubercle.  Of  all  tumors,  at  least  one-half 
are  tuberculous,  and  one-quarter  either  glioma  or  sarcoma.  The 
frequency  with  which  cerebellar  tumors  occur  is  noticeable. 

Etiology. — The  etiology  is  obscure  when  we  leave  out  the  two 
factors  of  injury  and  tubercle.     The  tuberculous  tumors  are  often 


SYMPTOMS  ;><>:»> 

multiple,  sharply  defined,  and  surrounded  by  softening,  lint  they 
rarely  break  down.  Gliomata  are  epithelial  in  origin,  infiltrating 
in  character,  and  prone  to  degeneration,  softening  and  cystic  forma- 
tion, and  sometimes  hemorrhage.'  They  are  slow  in  growth  but  do 
not  involve  the  bones  or  cause  secondary  deposits.  Sarcoma  is  most 
commonly  situated  in  the  cerebellum. 

The  influence  of  injury  is  probably  what  accounts  for  the  greater 
prevalence  among  boys. 

Symptoms. — GEXERAL  SYMPTOMS. — Of  all  the  symptoms,  head- 
ache is  the  most  prominent,  being  persistent,  generally  severe  (but 
not  so  severe  as  in  adults),  and  occasionally  intense.  Xot  uncom- 
monly it  occurs  with  most  marked  intensity  during  the  night  and 
in  the  early  morning.  Mental  effort  or  anything  which  increases 
intracranial  pressure  exaggerates  the  headache.  Occasionally  it  is 
localized  over  the  site  of  the  tumor  and  is  most  intense  when  the 
tumor  is  in  the  posterior  cranial  fossa,  the  pain  then  being  occipital 
and  radiating  into  the  neck. 

Tenderness  of  the  scalp  is  not  uncommon  in  cortical  tumors. 

Closely  associated  with  the  headache  there  is  the  occurrence  of 
vomiting  and  vertigo.  The  result  is  that,  for  a  short  time,  the  case 
may  simulate  headache  from  some  digestive  disturbance.  The 
vomiting,  however,  is  of  the  projectile  type  and  has  no  relation  to 
the  meals.  Like  the  headache  the  vomiting  and  vertigo  are  per- 
sistent, making  in  all  three  very  suggestive  symptoms.  Vertigo 
may  occur  even  while  the  child  is  reclining  and  may  be  described 
as  a  sense  of  falling  or  turning  (subjective  sign),  or  it  may  be 
stated  that  the  room  is  moving  (objective). 

In  about  four-fifths  of  all  the  cases  optic  neuritis  accompanies 
cerebral  tumors.  It  is  not  uniform  in  both  eyes  and  has  no  relation 
to  the  size  of  the  tumor. 

In  the  early  stage  of  the  disease  general  convulsions  are  com- 
mon, but  the  rule  is  that  there  are  long  periods  between  the  con- 
vulsive seizures  in  the  beginning.  This  may  lead  to  the  conclusion 
that  the  attacks  are  dependent  upon  other  causes.  All  degrees  of 
convulsions  are  observed  from  simple  twitchings  to  severe  and 
typical  epileptiform  seizures. 


294  INTBACRAXIAL   TUMORS 

The  mental  symptoms  show  the  greatest  variety  and  complexity, 
and  such  symptoms  are  so  frequent  in  childhood  during  the  course 
of  disease  that  they  are  not  apt  to  excite  suspicion  as  to  the  true 
condition  for  a  long  time.  At  first  there  is  very  apt  to  be  an 
irritability  which  is  unnatural  to  the  child,  followed  by  depression 
and  a  disinclination  to  play  or  to  be  amused.  Somnolence  may  be 
added  to  this,  although  it  may  not  be  noticeable  until  late  in  the 
disease. 

Any  child  who  suffers  from  headache,  associated  with  vomiting 
and  vertigo,  all  of  which  are  persistent  (although  not  necessarily 
severe),  and  who  is  at  the  same  time  persistently  and  increasingly 
somnolent,  must  be  regarded  with  suspicion.  Even  without  the 
somnolence,  which  may  be  of  later  occurrence,  we  still  have  three 
characteristic  symptoms:  persistent  headache,  vomiting,  and  optic 
neuritis.  If  vomiting  be  absent,  as  is  the  occurrence  in  rare  cases. 
then  optic  neuritis  is  also  apt  to  be  absent,  so  that  the  one  constant 
feature  of  intracranial  tumors  is  headache  (persistent).  Xow  if 
headache  alone  is  present  there  may  be  considerable  difficulty  in  the 
diagnosis  at  first.  The  only  thing  which  appears  to  affect  the 
severity  and  persistency  of  the  headache  is  the  occurrence  of  hydro- 
cephalus  and  when  this  is  well  developed  the  pain  may  entirely 
disappear.  Nystagmus  is  usually  of  late  occurrence  and  is  irrespec- 
tive of  the  situation  of  the  tumor.  Hydrocephalus  also  may  occur 
with  a  tumor  in  any  situation,  but  if  appearing  early  or  being  ex- 
treme in  degree,  it  indicates  that  the  lesion  is  obstructing  the  sylvian 
aqueduct  or  the  fourth  ventricle. 

The  pulse  alters  with  change  of  posture  and  is  infrequent,  slow, 
and  irregular. 

LOCAL  SYMPTOMS. — These  may  be  absent  or  few  at  first  and 
are  practically  always  slight  in  the  earlier  stages  and  increasing  with 
the  size  of  the  tumor,  a  very  sudden  increase  indicating  that  hemor- 
rhage has  taken  place. 

It  is  not  uncommon  to  observe  a  lesion  of  the  frontal  lobe  with- 
out obvious  signs.  Usually,  however,  there  is  evidence  of  mental 
impairment  which  may  be  observed  as  dulness  or  apathy,  or  may 
amount  practically  to  imbecility.  Fainting  attacks,  petit  mal. 


SYMPTOMS  295 

enurcsis,  and  coma  are  also  common  to  this  lesion.  Extending  back- 
ward, the  tumor  may  involve  by  pressure  the  motor  area  and  cause 
convulsions  on  the  opposite  side  of  the  body. 

An  inability  to  write  indicates  involvement  of  the  left  frontal 
convolution  and  motor  aphasia  of  the  third  frontal  gyms. 

Sudden  loss  of  consciousness  or  an  impairment  of  it,  associated 
with  automatism,  is  characteristic,  but  may  also  occur  in  temporal 
and  occipital  lesions.  From  pressure  there  may  occur  brachial, 
facial,  or  crural  monoplegia,  or  even  hemiplegia,  which  occurs  grad- 
ually. There  may  be  either  unilateral  or  bilateral  anosmia.  Blind- 
ness is  not  uncommon. 

In  the  event  of  lesions  existing  which  are  destructive  to  the  cen- 
tral convolutions,  there  may  be  observed  paralysis  of  voluntary 
motion  in  the  corresponding  parts  of  the  body,  or  there  may  simply 
exist  an  impairment  which  shows  as  a  weakness. 

Inability  to  localize  touch  or  irritative  phenomena  is  quite 
common.  Localized  epilepsy  is  among  one  of  the  earliest  symptoms, 
but  usually  is  rapid  in  its  spread,  so  that  Jacksonian  convulsions 
may  involve  the  whole  side  of  the  body  within  a  short  time. 

Of  the  occipital  lobe,  the  most  characteristic  local  sign  is  bi- 
lateral homonymous  hemianopia.  If  on  the  left  side,  there  may 
be  word-blindness  and  an  inability  to  recognize  those  persons  or 
things  which  are  familiar  (physical  blindness).  There  may  also 
be  sensory  epilepsy,  visual  hallucinations,  and  visual  aura. 

Of  the  temporal  lobe,  there  may  be  an  alteration  of  the  mental- 
ity without  other  signs.  However,  when  the  other  signs  occur  they 
are  deafness,  word-blindness,  word-deafness,  or  a  total  loss  of  speech. 
Hallucinations  of  smell  and  of  taste  are  common,  but  their  loss  is 
infrequent. 

Involvement  of  the  internal  capsule  has  as  its  chief  characteris- 
tics hemiplegia,  hemianesthesia,  which  is  never  absolute,  and 
hemianopia.  Tumor  of  the  pons  presents  the  unusual  combination 
of  hemiplegia  with  crossed  facial  anesthesia. 

Ataxia  is  common,  as  is  also  intention  tremor.  Spastic  paralysis 
of  the  face  may  be  present,  also  deafness  and  hemianesthesia. 
Tumor  of  the  medulla  causes  atrophic  changes,  as  paralysis  of  the 


296  INTRACEANIAL   TUMORS 

lips,  palate,  pharynx,  and  larynx,  but  in  this  situation  a  tumor 
usually  proves  rapidly  fatal,  so  that  symptoms  are  not  observed  for 
any  considerable  period. 

The  signs  of  cerebellar  involvement  are  mostly  dynamic,  and  to 
be  well  demonstrated  the  general  mental  and  physical  condition  of 
the  affected  child  must  be  reasonably  good. 

Hemiataxia  (on  the  side  with  the  lesion)  is  frequent,  but  is 
more  pronounced  in  the  upper  than  in  the  lower  limb.  Movement 
is  unsteady  and  uncertain  when  an  attempt  is  made  at  the  finer 
adjustments.  In  most  of  the  cases,  the  head  is  inclined  to  the 
shoulder  of  the  same  side  as  the  lesion,  the  face  being  slightly 
turned  to  the  opposite  side.  This  is  most  noticeable  in  the  sitting 
position.  When  the  child  stands,  the  body  is  bent  toward  the  side 
with  the  lesion  and  there  may  a  tendency  to  fall  in  that  direction, 
for  the  child  is  very  unsteady.  While  walking,  the  child  does  so 
with  a  sort  of  lunge  and  progresses  in  a  curved  line.  Sometimes 
there  is  bilateral  ataxia  with  forward  bending  of  the  body  or  re- 
traction of  the  head  with  backward  inclination  of  the  body.  Nys- 
tagmus is  usually  marked  and  irritative  phenomena  are  sometimes 
prominent. 

There  has  been  no  attempt  in  considering  these  local  symptoms 
to  do  more  than  suggest  some  of  the  more  prominent  ones,  and  the 
finer  details  of  localization  must  be  studied  from  the  works  upon 
this  special  subject. 

Diagnosis. — The  diagnosis  is  at  times  difficult  and  for  a  period 
may  be  impossible.  It  depends  largely  upon  the  general  symptoms 
which  have  been  mentioned  as  characteristic,  but,  in  addition,  the 
local  signs  have  to  be  considered  secondarily. 

In  the  matter  of  localization,  Taylor  bases  a.  table  upon  the 
presence  of  hemiplegia  and  this  may  prove  useful. 

(1)  Pure  hemiplegia — the  tumor  is  above  the  tentorium. 

(2)  With  palsy  of  the  opposite  third  nerve — in  the  crus  cerebri. 

(3)  With  hemiataxy  and  nuclear  ocular  palsy — in  the  mesen- 
cephalon. 

(4)  With   hemiataxy   on    either   side    and    palsy    of    the    fifth, 
seventh,  and  eight  nerves  on  the  same  side — in  the  pons  varolii. 


DIAGNOSIS  297 

(5)  Without  facial  palsy,  with  hemiataxy  on  the  opposite  side. 
and  with  alternate  palsy  of  the  ninth  to  twelfth  nerves — in  the 
medulla. 

When  optic  neuritis  exists  alone  or  in  association  with  headache 
and  vomiting,  it  at  once  leads  to  a  suspicion  of  organic  disease  of 
the  brain,  of  kidney  disease,  lead  poisoning  or  grave  anemia.  The 
two  latter  can  usually  be  easily  eliminated,  for  there  is  the  history 
of  lead  colic  in  the  one  and  the  impoverishment  of  the  blood  must 
be  extreme  in  the  other  to  cause  such  symptoms.  Uncertainty  could 
not  exist  long. 

Also,  in  anemia,  the  neuritis  is  of  rapid  development  as  com- 
pared with  tumor  and  the  influence  of  treatment  is  quickly  ap- 
parent. 

Kidney  lesions  would  be  revealed  by  urinalysis  and  headache 
is  not  extreme  or  persistent. 

It  is  with  other  brain  diseases  that  tumor  is  apt  to  be  confused. 
If  basilar  meningitis  be  slowly  developed,  it  may  for  a  time  simulate 
intracranial  tumor  but  in  the  latter  there  is  an  entire  absence  of 
fever,  of  the  slow  and  retarded  pulse,  of  the  constipation,  of  the  re- 
tracted abdomen,  and  of  the  pupillary  changes. 

The  onset  of  tuberculous  meningitis  is  more  rapid  than  tumor, 
and  the  prodromes,  the  wasting,  the  history,  the  tuberculin  tests, 
and  lumbar  puncture  are  sufficient  to  make  the  distinction  soon 
clear. 

In  some  instances  the  symptoms  of  a  slow  onset  of  local  signs 
with  a  progressive  course  are  not  due  to  tumor  (although  they  simu- 
late it),  but  are  occasioned  by  an  enlarging  focus  of  disseminated 
sclerosis  involving  one  of  the  peduncles  of  the  cerebellum.  In  those 
instances  the  optic  discs  are  pale  and  other  symptoms  finally  appear, 
although  they  may  be  long  delayed. 

Hemorrhage  could  hardly  offer  a  difficulty,  as  its  onset  is  sud- 
den, in  marked  contrast  to  that  of  tumor,  and  the  symptoms  show 
periods  of  progressive  improvement  instead  of  progressively  growing 
worse. 

The  differential  diagnosis  between  intracranial  tumor  and  cere- 
bral abscess  has  already  been  fully  considered  (see  page  291). 


298  THE   PARALYSES   OF    CHILDHOOD 

CHAPTER  XLII 

THE    PAKALYSES    OF    CHILDHOOD 

To  the  surgeon  working  among  children  there  will  be  presented 
from  time  to  time  instances  in  which  one  or  more  limbs  are  partly 
or  completely  paralyzed.  Or,  as  is  more  commonly  the  case,  the 
child  is  presented  because  of  the  persistence  of  some  contracture 
or  some  more  or  less  marked  deformity  which  is  dependent  upon 
the  paralysis  or  the  contracture.  In  some  few  instances  there  may 
exist  a  combination  of  all  of  these. 

We  must  admit  that  the  treatment  of  the  results  of  the  several 
forms  of  paralysis  has  much  in  common  as  regards  the  advisability 
of  the  repair  and  transference  of  nerves,  the  performance  of  tenot- 
omy,  or  of  tendon  shortening,  lengthening,  or  transplantation  and 
also  as  regards  the  technique  when  these  are  performed,  but  it  is 
quite  necessary  that  the  surgeon  be  able  to  make  the  direct  and 
differential  diagnosis  clear. 

In  this  section  it  is  necessary  for  us  to  consider  the  following: 

Poliomyelitis,  an  acute  disease,  due  to  an  inflammation  of  the 
anterior  portion  of  the  cord  principally,  but  with  possible  further 
extension;  Erb's  paralysis,  or  paralysis  of  the  arm  in  the  new-born; 
infantile  cerebral  paralysis,  from  a  lesion  within  the  cranium ; 
pressure  paralysis;  paralysis  of  the  musculospinal  nerve,  and  facial 
paralysis. 

ACUTE  POLIOMYELITIS 

We  should  not  allow  the  confusion  of  many  names  to  lead  us 
astray  in  regard  to  the  definite  facts  which  are  known  of  this 
disease  because  of  its  close  study  and  investigation  within  very 
recent  times,  especially  by  Flexner  in  this  country. 

Acute  anterior  poliomyelitis,  infantile  spinal  paralysis,  acute 
atrophic  spinal  paralysis,  myelitis  of  the  anterior  horns,  infantile 
atrophic  paralysis,  infantile  paralysis,  essential  paralysis  of  chil- 


ACUTE    POLIOMYELITIS 


299 


YEAR       OF      LIFE 


\2 


dren — these  are  some  of  the  many  names  by  which  the  disease  is 
variously  known. 

Of  all  the  forms  of  paralysis  occurring  in  childhood,  this  is  the 
most  frequent  and  yet,  with  this  common  occurrence,  there  are  still 
constantly  arising  facts  in  regard  to  the  disease  which  are  difficult 
for  the  diagnostician  in  particular. 

The    age    incidence    is  of  considerable  interest  because  it  is  mainly 
a  disease  of  early  childhood  and  it  might  be  noted  that  the  central 
nervous    system    seems    especially    susceptible   to   infection    at   this 
period  of  life,   as  is  no- 
ticed by  the  more   com- 
mon occurrences  of  sup- 
purative,      cerebrospinal, 
and  tuberculous  meningi- 
tis before  the  end  of  the 
third  year. 

The  most  common  de- 
velopment is  during  the 
second  year  of  life  and 
this  should  receive  spe- 
cial mention  because  it 
contrasts  with  the  first- 
y  e  a  r  age-incidence  o  f 


FIG.  106. — AGE  INCIDENCE  IN  POLIOMYELITIS  AS 
OBSERVED  IN  THE  1909  EPIDEMIC  IN  BROOKLYN, 
N.Y.,  BY  THE  AUTHORS. 


cerebral    hemiplegia.     It 

will  be  noted  by  reference 

to     the    accompanying 

chart  that,  while  seventy-two  cases  occurred  during  the  first  three 

years  of  life,  there  was  a  decided  maximum  incidence  during  the 

second  year.     The  earliest  onset  was  at  four  months. 

The  seasonal  incidence  is  even  more  interesting  than  the  age- 
incidence  and  this  can  be  best  studied  from  the  accompanying  chart. 
The  earliest  case  occurred  in  the  authors'  series  in  the  month  of 
May,  and  the  latest  during  November,  and  of  all  the  cases  the  sea- 
sonal incidence  reached  its  maximum  in  September. 

It  must  be  remembered,  however,  that  it  is  true  of  all  the  infec- 
tions of  childhood  that  the  symptomatology  occurs  distinctly  seasonal 


300 


THE   PARALYSES   OF   CHILDHOOD 


and  varies  with  each  particular  epidemic  and  especially  with  the 
type  of  child  affected.  For  instance,  we  do  not  expect  the  rachitic 
or  malnourished  child  to  respond  in  the  same  manner  as  his  normal 
brother  and,  besides  this,  there  is  the  important  influence  of  age  or 
immaturity.  In  the  presence  then  of  a  disease  which  has  been  long 
recognized,  but  only  recently  carefully  studied,  we  find  abundant 
cause  for  the  conflicting  statements  as  to  the  manifestations  of  the 
acute  stage. 

Symptoms. — ONSET. — We  might  reasonably  divide  these  mani- 
festations into  three  somewhat  distinct  periods:  the  period  of  onset, 

of  paralysis,  and,  finally, 
of  retrogression. 

The  symptoms  of  the 
period  of  onset  are  by  no 
means  constant  and  may 
exhibit  such  a  variability 
that  there  are  three 
rather  distinct  types  of 
onset.  The  commonest 
type  of  onset  is  that  of  an 
acute  illness  of  an  indefi- 
nite nature,  lasting  from 
two  to  three  days,  with 
symptoms  of  fever,  diar- 
rhea, vomiting,  and  some 
malaise  prominent,  and 

followed  by  paralysis.  There  may  be  other  symptoms  present,  as 
dysphagia,  constipation,  cough,  and  an  undue  restlessness,  but  these 
usually  do  not  excite  any  particular  attention  or  comment.  On  the 
other  hand,  there  may  be  a  prolongation  of  this  symptomatology  over 
a  period  of  several  days.  In  a  small  proportion  of  the  cases  the 
nervous  phenomena  are  so  prominent  that  they  make  one  suspicious 
of  a  cerebral  rather  than  a  spinal  affection. 

A  less  common  onset  than  the  preceding  is  that  in  which  there 
is  very  apparent  suddenness,  which  is  probably  more  apparent,  how- 
ever, than  real.  It  is  more  than  likely  that  most  of  the  cases  with 


OSES!  JAN  I  FEB  I  HCH  I  APR  I  MAY  |  MH  \  JUl  |  AUG  I  SEP  I  OCT  I  NOV  I  DEC 


FIG.  107. — SEASONAL  INCIDENCE  or  POLIOMYELITIS 
AS  OBSEKVED  BY  THE  AUTHORS  IN  1909. 


ACUTE    POLIOMYELITIS  301 

such  an  onset  terminate  fatally  before  an  accurate  diagnosis  can  be 
made  and  are  often  reported  as  instances  of  meningitis,  when  the 
real  condition  present  is  an  involvement  of  the  cervical  portion  of 
the  cord. 

An  insidious  onset,  without  any  serious  general  manifestations, 
the  disease  going  through  the  successive  stages  without  some  promi- 
nent symptom  to  give  the  clew,  is  the  rarest  type  of  onset  in  chil- 
dren. Or,  in  other  words,  a  true  subacute  or  chronic  course  through- 
out all  of  the  stages  of  the  disease  is  at  best  rare.  In  these  cases 
the  paralysis  is  not  marked  as  such,  but  is  exhibited  as  a  muscular 
weakness  followed  by  wasting. 

It  is  extremely  doubtful  if  the  disease  ever  occurs  in  fetal  life; 
and,  of  the  early  cases  which  have  been  reported  as  occurring  dur- 
ing the  first  few  days  or  weeks  of  life,  the  more  probable  diagnosis 
is  hemorrhage  rather  than  poliomyelitis. 

There  does  not  seem  to  be  any  difference  in  the  affection  of  the 
sexes  and  a  close  study  of  many  epidemics  will  show  that  this  is  a 
very  variable  factor. 

In  regard  to  the  individual  symptoms: 

Fever  is  present  in  about  eighty  per  cent,  of  the  cases  and  when 
confirmed  by  the  thermometer  shows  a  range  from  100°  F.  to  102° 
F.  as  the  rule,  and  the  higher  temperatures  as  the  exception.  The 
rise  in  temperature  usually  persists  until  the  occurrence  of  the 
paralysis,  at  which  time  it  is  either  much  lowered  or  disappears. 
Exceptional  cases  exhibit  a  persistency  of  the  temperature  rise  after 
the  onset  of  the  paralysis  and  this  is  usually  accompanied  by  con- 
stitutional disturbances  also. 

Diarrhea  is  present  in  over  one-half  of  the  cases,  but  there  is 
nothing  about  the  number  or  the  character  of  the  stools  which  is 
in  any  way  suggestive. 

Vomiting  is  rarely  a  prominent  feature,  but  occurs  in  some  de- 
gree in  about  one-third  of  the  cases,  and  its  most  common  occurrence 
is  at  the  onset  of  the  fever  and,  therefore,  there  is  always  some 
doubt  as  to  whether  it  is  due  to  the  onset  of  the  disease  or  is  the 
result  of  a  digestive  fault  at  the  onset  of  an  elevation  of  the  body 
temperature.  It  is  always  transient  and  never  projectile. 

LlBl\«Uv\    OF 
COLLEGE  OF  OSTl£Ol=.0 

»H;N  ilv'S-    N      J^l'Kl-.lE1 


302 

Cough  is  very  common  and  occurs  without  any  detectable 
physical  signs  to  account  for  it.  It  is  present  in  one-third  of  the 
cases. 

Constipation  occurs  in  a  small  proportion  of  the  cases. 

Difficulty  in  deglutition  is  not  uncommon  and  this  is  irrespective 
of  any  condition  in  the  throat  to  account  for  it.  Occurring  in  about 
30  per  cent,  of  the  cases,  it  is  one  of  the  earliest  symptoms. 

Rigidity  of  the  neck  musculature  is  infrequent  and,  when  it 
does  occur,  its  onset  is  sudden  and  there  are  distinct  periods  during 
which  complete  relaxation  takes  place  and  it  therefore  has  no  more 
significance  than  the  similar  rigidity  of  a  temporary  nature  which 
occurs  in  practically  all  of  the  infections  in  children. 

Transitory  loss  of  sensibility  may  at  times  be  noted  in  the  cases 
that  are  seen  early. 

Pain  is  present  in  more  or  less  degree  in  practically  every  case 
and  can  be  easily  elicited  by  gentle  squeezing  of  the  muscles.  This 
sensitiveness  of  the  musculature  is  irrespective  of  the  muscles  which 
are  affected,  being  quite  general.  After  the  first  few  days  the  pain 
is  more  strictly  localized  in  the  affected  muscles  and  is  apt  to  be 
more  marked  than  previously. 

While  there  is  nothing  suggestive  about  these  symptoms  when 
taken  individually,  there  are  combinations  of  them  that  are  of  great 
value  in  the  presence  of  a  known  epidemic.  The  commonest  com- 
binations are  fever,  diarrhea,  and  cough,  with  or  without  dysphagia 
and  fever,  vomiting,  cough,  and  diarrhea.  Other  combinations  are 
much  less  common. 

PARALYSIS. — Such  combinations  of  symptoms  may  continue  for 
three  or  four  days  and  subside  without  paralysis  following.  How 
often  this  occurs  during  an  epidemic  it  is  impossible  to  determine, 
but  there  are  probably  a  large  proportion  of  such  instances.  In 
other  cases  there  is  muscular  weakness  persisting  for  several  days 
and  out  of  all  proportion  to  the  severity  of  the  initial  symptoms,  but 
no  paralysis. 

Typical  cases  are,  however,  not  of  this  abortive  type,  but  the 
symptoms  of  the  onset  are  followed  by  paralysis.  The  interval  be- 
tween the  symptoms  of  the  onset  and  the  occurrence  of  the  paralysis 

A'lO'STgO    ~,Cj   H0HJJG5 


303 

varies  greatly.'  The  onset  of  the  paralysis  may  be  apparently  so 
sudden  that  no  symptoms  have  been  noted  as  preceding  it,  so  that 
it  is  not  uncommon  to  get  a  history  of  the  child  retiring  at  night 
in  health  and  arising  paralyzed  in  the  morning.  However,  care- 
ful history  taking  eliminates  practically  all  of  these  instances,  for 
it  is  shown  that  mild  but  unnoted  symptoms  were  present,  the 
calamity  of  the  paralysis  overshadowing  them.  The  paralysis  may 
occur,  however,  as  early  as  within  twenty-four  hours  (or  in  rare 
instances  less),  or  may  be  delayed  until  the  second  week.  The 
average,  however,  is  for  its  occurrence  upon  the  second  or  third  day. 

The  typical  paralysis  is  that  wrhich  shows  a  loss  of  power  in 
some  muscles  with  flaccidity.  It  seems  clear  that  the  portions  of 
the  cord  remote  from  the  brain  are  most  commonly  affected,  as  is 
shown  by  the  lower  limbs  being  most  often  affected. 

The  first  onset  of  the  paralysis  is  never  an  indicator  of  what 
the  ultimate  result  will  be.  In  a  few  instances  the  progressive 
nature  of  the  paralysis  is  very  marked,  muscle  after  muscle  being 
affected  in  succession.  But  the  commoner  occurrence  is  to  observe 
a  more  or  less  widespread  paralysis  at  the  onset  with  subsequent 
clearing  up  to  a  decided  degree.  Within  a  few  days  the  preserva- 
tion of  the  normal  electrical  irritability  will  enable  the  examiner  to 
pick  out  the  muscles  which  are  capable  of  more  or  less  regenera- 
tion. In  no  other  condition  is  there  such  an  early  loss  of  response 
to  the  faradic  current. 

The  tendon-jerks  are  rapidly  lost  in  the  affected  limbs,  but  this 
loss  depends  upon  the  distribution  of  the  paralysis ;  there  may  be 
extensive  paralysis  of  the  legs  with  no  loss  of  knee-jerk,  so  long 
as  part  of  the  quadriceps  extensor,  particularly  the  vastus  internus, 
is  intact. 

Atrophy  of  the  musculature  may  be  present  as  early  as  the  end 
of  the  first  week,  although  its  later  occurrence  is  the  rule.  The 
usual  course  is  for  the  paralysis  to  progressively  improve  for  a 
period  of  three  months  and  atrophy  to  occur  not  earlier  than  within 
four  to  eight  weeks.  The  growth  of  the  limb  is  arrested  and  it 
becomes  shorter  and  smaller  than  the  unaffected  one. 

There  is  another  type  of  the  disease  which  is  rarely  seen  except 


304 


THE   PAKALYSES   OF    CHILDHOOD 


in  epidemics  and  which  shows  an  involvement  of  the  cranial  nerves, 
indicating  a  bulbar  lesion.  In  this  type,  more  or  less  severe  or  con- 
tinued convulsions  may  be  added  to  the  usual  symptomatology,  or 
a  single  convulsion  may  be  followed  by  stupor  or  delirium.  Paraly- 
ses involving  the  face,  trunk,  and  neck  are  common  and  there  may 
be  difficulty  in  swallowing. 

Diagnosis. — It  is   impossible  to  make  the  diagnosis  before  the 

occurrence  of  paralysis  with- 
out the  aid  of  lumbar  punc- 
ture. If  lumbar  puncture  is 
performed  early  the  fluid  is 
found  to  be  opalescent  or 
slightly  turbid,  on  account 
of  the  many  mononuclear 
cells  and  not  uncommonly 
such  a  fluid  will  coagulate 
spontaneously.  Xoguchi's 
globulin  test  shows  positive 
reaction.  With  the  occur- 
rence of  the  paralysis  there 
is  a  gradual  clearing  up  of 
the  fluid,  and  within  a  very 
few  days  there  is  nothing  left 
by  which  we  can  distinguish 
the  disease. 

Differential  diagnosis  is 
difficult  at  first  because  there 
is  nothing  in  the  prodromal 

symptoms  to  arouse  a  suspicion  of  the  disease,  except  in  the  presence 
of  an  epidemic,  so  that  many  errors  are  made  either  through  a  too 
hasty  diagnosis  or  through  too  much  regard  for  one  symptom.  The 
onset  of  one  of  the  acute  infectious  diseases,  diseases  of  the  joint, 
rheumatism,  and  many  other  conditions  will  be  diagnosed  as  a  result 
of  the  prodromal  symptoms,  and  it  is  only  with  the  occurrence  of 
the  paralysis  that  the  diagnosis  is  made  definite. 

The  appearance  of  early  cerebral  symptoms  makes  the  differ- 


Fio.  108. — ATROPHY  OP  THE   MUSCTTLATUBB 
OF  THE  LEG  FOLLOWING  POLIOMYELITIS. 


ACUTE    POLIOMYELITIS 


305 


entiation  between  this  disease  and  cerebrospinal  meningitis,  or  even 
tuberculous  meningitis,  quite  impossible  without  the  aid  offered  by 
an  accurate  bacteriological  examination  of  the  fluid  obtained  by  lum- 
bar puncture. 

When  the  disease  is  observed  in  its  later  stages  there  may  be 
some  difficulty  offered  by  cerebral  palsies,  multiple  neuritis,  or  a 
pseudoparalysis. 

In  regard  to  infantile  cerebral  paralysis  and  poliomyelitis,  they 
both  affect  children  of  quite 
similar  ages  (as  before  the 
third  year  of  life),  but  the 
maximum  age-incidence  of 
the  former  is  during  the  first 
year  of  life.  The  mode  of 
onset  is  quite  similar  in  both 
diseases  in  that  paralysis 
quickly  follows  some  indefi- 
nite symptomatology.  The 
paralysis  in  both  may  be  lo- 
calized in  an  entire  limb,  or 
affect  certain  muscles  of  a 
limb.  Now,  while  these  sim- 
ilarities are  marked,  the  dif- 
ferences are  also  clear.  Cere- 
bral paralysis  is  unilateral 
and  the  usual  form  is  hemi- 
plegia  and  if  but  one  member 
be  affected  it  is,  by  a  prepon- 
derating preference,  the  arm,  and  if  two  limbs  are  affected  then  the 
arm  and  the  leg  of  the  same  side. 

In  the  cerebral  paralysis  there  is  an  absence  of  any  electrical 
change  in  the  affected  muscles,  but  this  is  difficult  to  determine  in 
children.  In  cerebral  paralysis  the  reflexes  are  exaggerated,  while 
in  the  spinal  type  they  are  diminished  or  lost. 

After  a  case  of  poliomyelitis  has  persisted  for  a  long  time,  that 
is,  until  such  time  as  the  paralyzed  musculature  begins  to  show 


FIG.  109. — HERNIA  OF  THE  ABDOMINAL  WALL 
DUE  TO  PARALYSIS  OF  THE  ABDOMINAL  MUS- 
CLES IN  POLIOMYELITIS. 

The  authors  observed  several  such  cases  during 
the  1909  epidemic. 


306  THE    PARALYSES   OF    CHILDHOOD 

atrophic  changes,  it  may  readily  be  mistaken  for  one  of  the  follow- 
ing conditions:  muscular  dystrophy,  multiple  neuritis,  acute  trans- 
verse myelitis,  pseudoparalysis  of  scurvy  or  rickets,  and  paralysis 
following  acute  meningitis.  As  it  is  at  this  stage  of  the  disease, 
or  later,  that  the  child  is  brought  to  the  surgeon's  attention,  it  is 
most  important  that  these  be  differentiated. 

The  distinction  from  muscular  dystrophy  is  usually  easy,  for 
the  history  is  entirely  different,  but,  in  the  instances  in  which  a 
definite  and  clear  history  is  impossible  to  obtain,  the  facts  then  to 
be  considered  carefully  are  that,  in  muscular  dystrophy,  all  the 
limbs  are  usually  affected  and  if  it  is  of  the  pseudohypertrophic 
type  certain  muscles  are  enlarged.  There  is  an  absence  of  the  cold- 
ness and  cyanosis  of  the  affected  limb,  as  is  common  in  poliomyelitis. 

Multiple  neuritis  is  generally  distinguished  by  its  gradual  onset 
and  by  the  presence,  more  or  less  prominently,  of  sensory  symptoms, 
as  pain  (which  is  usually  along  the  course  of  the  affected  nerve) 
and  alterations  in  the  sense  of  touch,  temperature,  and  the  muscular 
sense.  Besides  this  there  are  the  history  and  possibility  (if  enough 
time  has  elapsed)  of  spontaneous  recovery. 

But  at  times  the  onset  of  multiple  neuritis  is  sudden,  with 
febrile  symptoms  and  an  early  paralysis,  and  the  sensory  symptoms 
are  not  marked,  and  under  these  circumstances  it  is  almost  impos- 
sible to  make  an  early  diagnosis.  The  course  of  the  disease  is  the 
main  point  upon  which  the  surgeon  must  rely. 

Acute  transverse  myelitis  at  the  onset  may  simulate  poliomye- 
litis, but  in  the  former  there  are  decided  anesthesia,  exaggerated 
knee-jerks,  ankle-clonus,  and,  what  is  quite  distinct  from  poliomye- 
litis, there  is  usually  an  involvement  of  the  sphincters.  The  reflexes 
at  the  level  of  the  lesion  are  usually  lost.  But  the  chief  character- 
istic is  that,  besides  acute  transverse  myelitis  being  rare  in  children, 
there  is  more  or  less  anesthesia  developed  simultaneously  with  para- 
plegia. 

Pseudoparalysis  of  scurvy  or  rickets  is  a  condition  which  must 
be  considered  on  account  of  former  errors.  The  pain  in  the  limbs, 
the  extreme  wasting  of  the  muscles,  and  the  general  indefiniteness  of 
many  of  the  symptoms  make  the  differentiation  sometimes  difficult. 


ACUTE    POLIOMYELITIS 


sor 


There  should  always  be  a  search  made  for  the  associated  symptoms 
of  scurvy,  and  the  gums  will  give  valuable  evidence,  particularly 
if  any  teeth  are  present.  The  spongy  gums,  which  bleed  readily, 
the  pain  upon  motion  of  any  kind,  and  the  general  tenderness  and 
hyperesthesia  all  tend  to  the  exclusion  of  spinal  disease. 

The  muscular  weakness  due  to  rickets  is  sometimes  mistaken 
for  a  flaccid  paralysis,  but  the  electrical  reactions  are  normal,  the 
condition  is  always  bilateral,  and  other  evidences  of  rickets  are 
present. 

Acute  meningitis  may 
be  followed  by  paralysis 
with  flaccidity  and  atro- 
phy, and,  if  observed  at 
this  stage,  may  simulate 
poliomyelitis.  The  paraly- 
sis, however,  is  always  pre- 
ceded by  signs  of  irritation 
and  the  sensory  symptoms 
are  usually  marked.  Pain 
is  severe  and  increased  by 
motion  or  pressure.  The 
history  would  aid  in  ex- 
cluding the  possibility  of 
anything  but  meningitis. 

Prognosis. — It  is  pos- 
sible for  complete  recovery 
to  take  place  without 
paralysis  or  even  after 
there  has  been  an  extensive  loss  of  power,  but  unfortunately  this  is 
the  uncommon  rather  than  the  usual  occurrence.  In  most  instances 
there  is  some  residual  paralysis.  The  symptoms  upon  which  is  based 
the  opinion  as  to  the  extent  of  permanent  paralysis  are  the  amount 
of  wasting  and  the  electrical  reactions.  Loss  of  faradic  contractility 
within  ten  days  is  good  evidence  that  atrophy  will  occur  early  and 
be  marked.  The  most  favorable  indication  of  improvement  is  the 
return  of  faradic  contractility,  and  if  this  is  lost  for  several  months 


FIG.   110. — FLAIL-LIKE    LIMB,    THE    RESULT    OF 

PARALYSIS   AND   ATROPHY   OF   POLIOMYELITIS. 
Note  the  atrophy  of  the  arm  and  evident  laxity 
of  the  ligaments  of  the  shoulder. 


308  THE   PAEALYSES   OF   CHILDHOOD 

(4  to  6)  recovery  is  very  doubtful,  and  if  delayed  longer  than  six 
months  the  chances  of  recovery  are  practically  nil. 

Persistence  of  faradic  contractility  is  a  most  hopeful  sign. 

The  danger  to  life  is  greater  than  has  previously  been  supposed, 
because  many  of  the  very  acute  cases  which  have  proved  fatal  have 
been  variously  diagnosed.  Of  course,  the  mortality  varies  with  the 
particular  epidemic,  as  is  true  of  all  infections  in  children,  and 
the  figures  are  influenced  by  the  skill  of  the  particular  observer, 
but  may  be  placed  reasonably  as  about  ten  per  cent.  It  is  the  bulbar 
cases  particularly  which  cause  the  confusion,  because  the  acute 
symptomatology  leads  readily  into  erroneous  diagnoses. 

Mechanical  and  Operative  Treatment. — These  procedures  are  the 
only  ones  that  interest  the  surgeon,  for  he  rarely,  if  ever,  sees  the 
casein  its  early  acute  stages. 

The  object  of  all  mechanical  devices  is  to  prevent  or  to  limit 
the  deformity,  and,  further  than  that,  they  are  used  to  assist  the 
child  in  maintaining  its  equilibrium,  so  that,  with  such  devices, 
the  child  may  get  along  quite  comfortably.  Mechanical  devices 
should  not  be  used  however  to  overcome  deformity,  although,  used 
in  conjunction  with  operative  treatment  which  has  relieved  deform- 
ity, they  are  valuable  in  preventing  a  return  to  the  original  con- 
dition. 

Just ,  as  soon  as  paralysis  is  discovered,  the  affected  part  should 
be  placed  and  restrained  more  or  less  in.  the  natural  position,  not 
allowing  normal  muscles  to  act  against  unopposing  ones. 

In  the  large  majority  of  cases  the  child  is  brought  to  the  surgeon 
because  of  deformity,  and  when  this  is  corrected  it  is  still  neces- 
sary that  the  surgeon  preserve  the  results  of  his  operative  procedure 
by  the  institution  of  subsequent  mechanical  treatment. 


ERB'S  PARALYSIS 

The  more  common  term  used  to  designate  this  form  of  paralysis 
is  birth  palsy.  Tt  consists  of  a  paralysis  of  one  or  both  upper  ex- 
tremities from  an  injury  to  the  brachial  plexus  during  labor. 


ERB'S    PARALYSIS  309 

Etiology.  — The  etiology  is  not  entirely  clear,  although  most 
observers  are  agreed  that  the  injury  is  inflicted,  in  breech  cases,  at 
the  time  that  the  shoulder  is  pulled  upon  so  as  to  make  easy  the 
delivery  of  the  head,  or  when  the  arm  is  pulled  down  if  it  lies 
above  the  head,  or  elevation  of  the  arm  upward  and  backward  caus- 
ing compression  of  the  nerves. 

In  vertex  presentations  it  may  be  due  to  the  pressure  of  the 
forceps,  depression  of  the  shoulder  with  the  head  bent  to  the  op- 
posite side  and  rotated,  lack  of  flexion  in  face  presentations,  or  to 
excessive  or  prolonged  traction  on  the  head.  It  has  also  been 
ascribed  to  constriction  by  the  cord  and  has  more  rarely  followed 
apparently  normal  labors  in  which  traction  has  not  been  a  factor. 

Pathology. — Whatever  the  direct  method  of  production,  the  lesion 
is  located  in  the  fifth  cervical  nerve  and  the  sixth  cervical  in  prac- 
tically every  instance. 

There  may  be  several  degrees  of  injury,  as  complete  rupture, 
rupture  of  a  few  of  the  nerve  fibers,  or  stretching  or  rupture  of  the 
sheath  of  the  nerve,  and  involvement  of  the  nerve  fibers,  possibly 
with  an  associated  hemorrhage,  or  there  may  occur  a  bruising  of 
the  nerve  from  direct  compression. 

The  cicatricial  changes  and  neuritis,  which  are  sometimes  found, 
are  secondary.  The  axis  cylinders  are  destroyed  and  between  their 
ends  there  occurs  the  formation  of  new  connective  tissue. 

The  disability  of  the  musculature  is  dependent  upon  the  extent 
of  the  injury  plus  the  anatomical  variations  which  may  exist  in 
the  plexus  formation.  If  the  fifth  nerve  is  involved  alone  and  there 
are  no  complications,  the  deltoid,  biceps,  spinati,  brachialis  anticus, 
supinators,  and  radial  extensors  of  the  wrist  are  involved.  If  the 
sixth  nerve  be_  involved  also,  then  there  is  further  involvement  of 
the  musculature  and  the  pectorals,  latissimus  dorsi,  and  triceps 
suffer.  With  complicating  involvement  of  the  seventh  nerve,  the 
extensors  of  the  fingers  are  affected.  If  the  whole  plexus  be  involved 
in  the  injury,  there  occurs  a  complete  paralysis  of  the  whole  of  the 
lirnb. 

Occasionally  there  may  be  observed  a  "lower  arm"  form  of 
paralysis  and,  while  it  is  possible  for  such  to  exist  as  a  primary 


310  THE   PARALYSES   OF   CHILDHOOD 

condition,  yet  in  nearly  every  instance  it  will  be  found  that  it  is 
the  persistence  of  some  of  the  paralysis  which  has  previously  in- 
volved the  whole  of  the  limb. 

In  practically  every  instance  the  deltoid  suffers  the  most  and 
may  be  the  only  muscle  affected. 

Diagnosis. — The  diagnosis  is  not  always  easy,  for  the  condition 
may  be  overlooked  for  weeks  if  the  paralysis  is  not  extensive.  It 
may  simply  be  noted  that  the  infant  does  not  use  the  arm  as  freely 
as  it  should,  and  such  an  occurrence  usually  does  not  attract  any 
particular  attention.  The  more  common  situation  is  that  the  arm 
is  held  loosely  at  the  side  of  the  body  and  is  not  moved.  The  limb 
is  rotated  inward,  the  forearm  extended,  pronated,  and  incapable 
of  flexion  or  supination,  and  the  hand  turned  back  and  slightly 
flexed. 

It  is  very  difficult  to  estimate  in  the  infant  just  what  degree 
of  loss  of  sensation  has  taken  place,  but  as  far  as  we  are  able  to 
demonstrate  it  its  degree  and  extent  are  slight,  except  in  the  occa- 
sional severe  injury. 

Muscular  atrophy  is  noticeable  within  a  few  weeks  and  this, 
like  the  paralysis,  may  be  overlooked  for  a  long  time.  This  is  so 
because  the  muscle  is  so  small  in  infants  and  is  so  well  covered  with 
fat.  The  reaction  of  degeneration  may  be  present. 

Contraction  of  the  affected  musculature  or  the  unopposed  action 
of  the  normal  musculature  may  result  in  early  rigidity. 

The  paralysis  may  be  further  complicated  by  partial  involve- 
ment of  the  sympathetic,  or  by  fracture  of  the  humerus  or  clavicle, 
or  a  separation  of  the  head  of  the  humerus,  facial  paralysis,  or 
wry-neck. 

The  diagnosis  is  not  difficult  if  the  case  is  typical  and  is  seen 
early.  However,  if  observed  late,  there  is  the  possibility  of  mis- 
taking it  for  poliomyelitis;  a  mistake  which  is  rather  easy  to  make 
unless  the  history  is  carefully  taken.  It  must  be  recalled  as  sug- 
gested previously  that  the  paralysis  may  be  unnoticed  for  several 
weeks  and,  therefore,  in  the  history  taking,  its  existence  from  birth 
will  be  .denied. 

When  there  is  a  complicating  injury,  as  fracture,  the  inability 


ERB'S    PAEALYSIS  311 

to  use  the  arm  may  be  attributed  to  that,  and  the  paralysis  may 
easily  be  overlooked.  It  is  necessary  therefore  to  exclude  fracture 
or  dislocation,  epiphysitis,  and  separation  of  an  cpiphysis,  or  if 
they  exist  as  complications  to  estimate  their  relation  to  the  amount 
of  disability  present.  In  eliminating  these  we  make  use  of  the 
fact  that  there  is  no  electrical  change  and  no  true  paralysis  is 
present. 

Paralysis  with  a  very  similar  distribution  may  occur  as  the 
result  of  other  injury,  pressure  from  enlarged  glands  or  tumors, 
or  from  neuritis  or  spinal  caries.  These  are  easily  excluded 
however. 

In  Erb's  paralysis  the  particular  muscle  group  which  is  affected 
is  quite  characteristic. 

Cerebral  palsy  is  rarely  monoplegic  and  still  more  rarely  limited 
in  its  distribution  to  a  particular  group  of  muscles. 

Prognosis. — The  prognosis  is  made  by  carefully  watching  the 
progress  of  the  disease  toward  spontaneous  recovery,  coupled  with 
a  consideration  of  the  extent  of  the  injury.  This  may  also  be 
further  influenced  by  the  amenability  to  surgical  interference. 

The  milder  cases  show  little  or  no  discomfort  and  improvement 
is  early  and  progressive  and  usually  complete.  Even  in  the  moder- 
ately severe  instances  if  recovery  starts  it  is  usually  progressive. 
In  these  instances,  however,  recovery  is  not  always  complete  and 
some  disability  may  be  permanent. 

Cases  that  will  eventually  recover  should  show  some  improve- 
ment in  from  one  to  three  months  and  be  fully  recovered  within  a 
year.  In  other  instances,  the  prognosis  is  not  good  unless  through 
surgical  intervention;  therefore  this  latter  should  be  undertaken  in 
all  cases  that  show  no  improvement  within  the  first  three  months, 
or  which,  having  exhibited  that  improvement,  show  an  arrest  of 
improvement  within  the  first  year. 

A  ready  response  to  faradic  irritation  is  a  favorable  sign,  but 
if  the  muscles  fail  in  their  response  to  faradism  and  yet  react  to 
galvanism,  surgical  intervention  should  be  instituted. 

Flexion  of  the  elbow  is  usually  the  first  sign  of  recovery  and 
further  progress  may  be  arrested  at  that  point. 


312  THE   PARALYSES   OF   CHILDHOOD 

The  unpleasant  and  disabling  sequels  of  atrophy,  contractures, 
and  maldevelopment  of  the  arm,  possibly  with  deformity  from  over- 
acting muscles,  may  be  the  remote  results. 

Treatment. — The  indications  for  treatment  are  clear.  At  first 
the  parts  must  be  kept  at  absolute  rest  to  allow  sufficient  time  for 
the  damaged  tissue  to  undergo  repair.  As  the  parts  are  rendered 
less  resistant  to  external  influence,  warmth  and  protection  should 
be  afforded  by  wrapping  the  arm  in  cotton  wool.  The  arm  should 
be  so  fastened  that  the  overstretched  muscles  are  mechanically  re- 
laxed for  weeks  or  months  if  necessary. 

After  the  first  month,  the  nutrition  of  the  parts  may  be  main- 
tained by  cutaneous  friction,  or  massage,  and  passive  motion.  If 
there  is  response  to  faradism,  the  current  should  be  used  regularly, 
making  each  muscle  contract  twenty  to  thirty  times  with  the  mildest 
current  possible.  In  the  case  of  no  response  to  faradism,  galvanism 
may  be  used  for  a  time  and  replaced  by  faradism  as  soon  as  pos- 
sible. Daily  use  of  electricity  gives  the  best  results. 

The  operative  treatment  is  considered  in  detail  elsewhere  and 
must  be  supplemented  by  electricity  and  massage. 


INFANTILE  CEREBRAL  PARALYSIS 

Under  this  term  there  are  included  several  groups  of  cases  which 
have  certain  common  clinical  features,  although  the  etiology  is 
very  different.  A  reasonable  division  would  be  into  three  groups: 
the  prenatal,  the  natal,  and  the  postnatal. 

The  prenatal  group,  or  paralysis  of  intrauterine  origin,  is  the 
least  frequent,  and  the  paralysis  is  due  to  defective  development 
or  possibly  to  intracranial  hemorrhages,  occurring  late  in  gestation. 
There  may  be  porencephalus  or  cysts  extending  into  the  brain 
substance. 

At  birth  such  an  infant  will  usually  show  some  loss  of  power, 
but  as  a  rule  this  is  not  the  prominent  feature.  What  is  much 
more  noticeable  is  that  there  exist  spastic  flexures  or  rigidity  of 
one  or  more  of  the  extremities.  The  type  of  the  paralysis  is 


INFANTILE  CEREBRAL   PARALYSIS  313 

generally  diplegic  or  paraplegic.  If  due  to  cortical  underdevelop- 
ment  there  may  be  general  flaccidity  in  place  of  the  more  character- 
istic spasticity.  Later  there  are  marked  evidences  of  mental  im- 
pairment, which  may  even  amount  to  idiocy  if  the  infant  lives. 

The  natal  group,  or  the  cerebral  birth-paralysis,  is  due  in  prac- 
tically every  instance  to  meningeal  hemorrhage.  The  instances  in 
which  prolonged  or  difficult  labor  and  the  use  of  the  forceps  are 
blamed  as  the  cause  may  exist,  but  such  an  origin  is  doubtful 
and,  at  best,  rare. 

The  primary  symptoms  as  a  rule  clearly  indicate  the  extent  of 
the  lesion.  If  widespread,  convulsions  ensue.  Diplegia  and  para- 
plegia develop  early  and  are  in  themselves  indicative  of  the  extent 
of  the  lesion ;  a  diffuse  lesion  resulting  in  diplegia ;  a  less  extensive 
one  in  paraplegia.  Hemiplegia  and  monoplegia  are  rare. 

With  the  survival  of  the  infant  through  the  first  stage,  the 
secondary  symptoms  will  depend  upon  the  extent  and  distribution 
of  the  lesion. 

Usually  there  is  more  or  less  rigidity  or  spastic  involvement  of 
the  extremities,  but  at  times  this  is  so  slight  that  the  infant  is 
brought  for  examination  because  of  a  supposed  general  weakness, 
or  a  mental  backwardness.  In  some  instances  the  condition  of  the 
limbs  is  duplicated  in  the  neck.  This  spastic  condition  of  the  ex- 
tremities may  be  well  marked  and  also  may  be  either  constant  or 
intermittent.  Head  retraction  and  opisthotonos  are  not  uncommon. 

The  general  condition  of  the  infant  is  always  poor  and  it  re- 
mains small  and  delicate.  This  renders  the  infant  less  resistant 
to  other  influences  and  many  of  them  die  in  early  infancy  from 
rather  slight  acute  causes.  We  have  observed  rarely  a  fairly  good 
physical  condition  with  marked  mental  impairment.  It  is  very 
difficult  to  demonstrate  the  degree  of  mental  impairment  until  the 
infant  reaches  its  second  year  of  life.  Speech  and  hearing  are 
both  affected  to  some  extent,  but  the  sight  is  rarely  involved.  The 
infant  may  not  be  able  to  sit  up  or  to  walk  until  it  reaches  the 
age  of  three  or  four  years,  and  then  the  gait  is  usually  a  crossed-leg 
one,  due  to  spasms  of.  the  adductors.  There  is  exaggeration  of  all 
the  reflexes  and  the  crossed-leg  posture  may  persist  even  when  the 


314        THE  PARALYSES  OF  CHILDHOOD 

child  is  at  rest.  Muscular  atrophy  is  marked  in  the  affected  parts 
as  a  rule.  The  arms  are  not  involved  as  commonly  as  the  legs  and 
in  about  50  per  cent,  of  the  cases  are  not  involved  at  all. 

In  the  milder  cases  the  diagnosis  may  be  delayed  because  there 
is  nothing  that  readily  excites  suspicion  until  the  infant  is  six  to 
eight  months  old  and  then,  as  the  infant  does  not  sit  up  or  advance 
normally,  the  muscular  weakness  is  noted  and  possibly  also  the 
tendency  to  spasm  of  the  musculature. 

The  symptoms  may  then  be  attributed  to  rachitis  or  looked  upon 
simply  as  an  evidence  of  general  backwardness,  but  a  careful  ex- 
amination reveals  the  spasticity  and  the  exaggeration  of  the  reflexes. 
Of  course,  as  the  infant  advances  in  age,  the  true  condition  becomes 
more  and  more  emphasized  and  the  recognition  of  it  is  rendered 
less  and  less  difficult. 

Epilepsy  develops  in  fully  one-half  of  the  cases,  usually  begin- 
ning as  the  Jacksonian  type  in  the  limb  which  was  most  affected 
and  then  becoming  general. 

The  postnatal  group,  or  acute  acquired  paralysis,  has  a  somewhat 
obscure  etiology  and  in  most  instances  it  is  impossible  to  determine 
whether  the  infant  exhibited  any  appreciable  disability  at  birth 
or  not.  Heredity  seems  to  play  no  part.  The  frequent  occurrence 
of  convulsions  at  the  onset  has  been  assigned  as  the  common  cause, 
but  there  is  good  reason  to  believe  that  it  is  the  lesion  that  precipi- 
tates the  convulsion  rather  than  that  the  convulsion  causes  the  lesion. 

The  lesions  are  those  of  the  blood  vessels,  the  membranes,  and 
the  brain  substance.  Of  the  blood  vessel  lesions  we  have  hemor- 
rhage as  the  most  important  and  usually  meningeal  (rarely  cere- 
bral) ;  embolism,  and  thrombosis.  Thrombosis  is  very  rare,  but 
embolism  may  occur  in  older  children  as  a  result  of  acute  rheumatic 
endocarditis.  The  lesions  in  the  membranes  are  generally  the  re- 
sult of  a  preceding  meningitis  or  may  be  due  to  syphilis.  The  brain 
substance  may  be  involved  by  atrophy  and  sclerosis,  although  these 
indicate  the  terminal  conditions  rather  than  the  earlier  ones. 

The  large  majority  of  cases  are  seen  during  the  first  year  of 
life. 

Diplegia  and  paraplegia  are  observed  occasionally,  but  the  char- 


INFANTILE    CEREBRAL    PARALYSIS  315 

acteristic  form  is  hemiplegia.  The  onset  is  sudden  and  convul- 
sions are  present  in  over  one-half  of  the  cases  and  these  may  be 
repeated  and  followed  by  a  state  of  unconsciousness.  After  thirty- 
six  hours  the  convulsions  are  not  apt  to  continue. 

There  are  an  associated  high  temperature  and  usually  more  or 
less  vomiting,  delirium,  and  other  symptoms  which  suggest  some 
inflammatory  condition  in  the  brain  and  these  may  persist  for  two 
to  three  days  before  the  discovery  of  any  paralysis.  The  tempera- 
ture rise  rarely  precedes  the  occurrence  of  the  convulsions.  The 
onset  of  the  paralysis  is  sudden. 

If  the  lesion  is  extensive,  all  that  may  be  noticed  with  the  acute 
onset  are  diplegia,  coma,  and  death,  but  this  termination  is  infre- 
quent. The  usual  course  is  that  there  is  observed  a  typical  hemi- 
plegia, with  only  a  slight  involvement  of  the  face,  or  with  entire 
exemption  of  the  latter. 

The  paralysis  is  at  first  complete,  reaching  its  maximum  of  in- 
tensity before  the  end  of  the  first  week  or  the  first  part  of  the  second 
week,  when  there  occurs  a  gradual  improvement.  With  left-sided 
lesions  the  speech  may  be  affected. 

During  the  height  of  the  paralysis  sensation  may  be  abolished, 
while  the  deep  reflexes  are  exaggerated  on  the  paralyzed  side. 
Spasticity  gradually  asserts  itself  and  may  always  be  detected 
when  a  careful  examination  is  made.  Laughing  and  crying  bring 
out  more  clearly  any  affection  of  the  face,  as  they  intensify  the 
stiffening  of  the  features  and  emphasize  the  loss  of  expression  upon 
one  side  of  the  face.  There  may  be  sluggish  movement  and  over- 
action  during  volitional  motion.  Sometimes  both  sides  of  the  face 
are  affected  by  spastic  paresis,  but  this  does  not  indicate  that  the 
lesion  involves  more  than  the  one  cerebral  hemisphere ;  it  is  probably 
the  result  of  muscle  innervation,  so  that  the  muscles  subserving  the 
bilaterally  associated  movements  of  the  face  are  not  as  active  as 
usual.  After  several  weeks  the  child  may  be  able  to  walk  and  drag 
the  affected  leg,  and  the  usual  course  is  for  some  interference  with 
the  gait  to  persist,  complete  recovery  being  rare.  The  arm  recovers 
more  slowly  than  the  leg  and  contractures  are  usual  after  two  or 
three  years. 


sic  THE  PARALYSES  OF  CHILDHOOD 

The  gait  in  walking  is  peculiar,  .because  the  limb  is  swung  at 
the  hip  and  brought  across  the  body  (generally  too  far),  and  because 
of  the  shortening  of  the  whole  limb.  This  results  in  the  walking 
being  almost  entirely  done  upon  the  toes,  resulting  in  compensatory 
tilting  of  the  pelvis  and  possibly  some  lateral  spinal  curvature. 
When  the  child  is  prone  the  limb  may  assume  the  hemiplegic  posi- 
tion and  to  all  appearances  is  a  useless  member,  but  with  the  child 
active  the  difference  is  marked. 

Disorders  of  motion  are  common  as  a  sequel.  They  are  chiefly 
of  two  classes:  (a)  defects  accompanying  voluntary  motion,  and  (b) 
spontaneous  movements.  Defects  of  the  first  class  usually  do  not 
appear  unless  there  is  considerable  voluntary  motion  possible.  All 
the  voluntary  movements  are  executed  with  more  or  less  evident 
effort,  the  motion  being  slow  and  stiff,  and  this  is  most  marked  after 
periods  of  rest.  Choreic  movements  are  common  when  muscular 
precision  is  attempted.  Spontaneous  movements  are  of  three  classes : 
(a)  choreic  when  the  spastic  contracture  is  not  marked ;  (b) 
athetosis  which  is  not  marked  except  in  the  parts  which  have  suf- 
fered most,  therefore  in  the  periphery;  (c)  tremor  which  usually 
accompanies  motion  and  which  may  persist  during  the  periods 
of  rest. 

As  regards  the  deformities  that  may  occur,  it  is  needless  to 
enumerate  them ;  all  that  is  essential  is  to  remember  their  mode 
of  production  and  then  their  nature  is  understood.  There  is  an 
arrested  development  which  affects  the  bones,  the  joints,  and  the 
•soft  tissues.  The  result  is  that  the  measurements  of  all  parts  are 
below  the  normal  with  two  exceptions:  First,  when  there  is  a  fat 
hypertrophy  of  the  part  and,  second,  when  athetosis  and  localized 
choreic  movements  are  present  in  such  degree  as  to  produce  hyper- 
trophy. 

The  atrophies  are  not  from  disuse  of  the  members,  but  are  due 
to  cerebral  innervation. 

The  mental  condition  may  remain  almost  normal,  but  the  earlier 
that  paralysis  occurs  the  more  certain  is  mental  insufficiency. 

The  diagnosis  between  the  congenital,  and  the  acquired  forms 
may  not  always  be  possible,  for  frequently  the  symptoms  of  the 


317 

congenital  type  are  so  mild  that  no  attention  is  paid  to  them  until 
the  time  arrives  for  the  infant  to  sit  up  or  walk.  Upon  the  other 
hand,  this  differentiation  is  not  really  important. 

Considerable  difficulty  may  be  encountered  in  making  the  diag- 
nosis from  poliomyelitis.  A  history  of  an  acute  onset,  absence  of 
sensory  symptoms,  the  atrophied  limbs,  and  deformities  may  be 
observed  in  both,  but,  on  the  other  hand,  the  spasticity,  the  presence 
of  perverse  or  spontaneous  movements,  preservation  of  electrical 
reactions  in  the  paralyzed  muscles,  and  the  retention  of  the  deep 
reflexes  are  distinguishing  signs  of  cerebral  paralysis.  The  onset 
with  acute  symptoms  usually  leads  to  a  suspicion  of  the  onset  of 
one  of  the  acute  infectious  diseases  or  of  meningitis.  The  differ- 
entiation is  made  by  lumbar  puncture,  which  gives  positive  results 
if  the  symptoms  are  due  to  meningitis,  and,  in  regard  to  the  acute 
infections,  close  observation  for  a  few  hours  and  the  occurrence  of 
hemiplegia  clear  up  any  doubt. 

The  treatment  is  unsatisfactory  because  the  conditions  asso- 
ciated with  the  occurrence  of  the  disease  make  interference  prac- 
tically impossible.  There  is,  therefore,  practically  nothing  left  to 
do  but  to  treat  symptomatically  and  to  limit  or  prevent  deformities 
or  complications. 

PRESSURE   PARALYSIS 

Edematous  swelling  is  the  result  when  the  blood  supply  of  a 
part  is  interfered  with,  as,  for  example,  the  result  of  a  too  tightly 
applied  bandage  or  splint.  While  the  whole  limb  may  be  painful, 
the  extremity  becomes  swollen  and  may  be  discolored  or  blue.  The 
muscles  are  apparently  paralyzed  and,  as  the  flexor  muscles  are 
stronger  normally  than  the  extensors,  within  a  few  days  there  occurs 
some  flexion.  There  are,  however,  no  true  paralysis  and  no  sensory 
changes.  Such  a  condition  may  come  on  very  rapidly  after  fracture 
and  finally  the  musculature  may  undergo  interstitial  fibrosis,  becom- 
ing therefore  smaller,  harder,  and  contracted. 

The  real  condition  present  in  many  instances  is  a  myositis  com- 
plicating a  neuritis. 


318  THE   PARALYSES   OF    CHILDHOOD 

Rest  and  warmth  are  usually  sufficient  to  effect  a  cure,  but  if 
fibrosis  has  occurred  no  treatment  is  of  any  avail.  Surgical  inter- 
vention may  become  necessary  on  account  of  a  subsequent  de- 
formity. 

MUSCULOSPIRAL   NERVE   PARALYSIS 

Musculospiral  nerve  paralysis,  or  radial  paralysis  as  it  is  some- 
times called,  may  occur  congenitally  on  account  of  an  amniotic  band 
or  intrapartum  pressure  on  the  nerve,  or  be  acquired  through  press- 
ure, fracture,  or  systemic  poisoning  (lead). 

The  results  are  paralysis  of  the  extensors  of  the  wrist,  flexion 
of  the  fingers,  and  wrist-drop. 

Peroneal  paralysis  and  crural  nerve  paralysis  may  be  due  to 
similar  causes. 

FACIAL  PARALYSIS 

Facial  paralysis  may  result  from  the  pressure  exerted  upon  the 
parts  at  the  time  of  birth,  particularly  when  a  difficult  forceps  opera- 
tion has  been  performed,  or  there  is  a  faulty  pelvis  or  one  in  which 
there  is  a  tumor  resulting  in  prolonged  labor  and  undue  pressure 
on  the  head. 

Subsequent  to  this  it  may  be  caused  by  meningitis,  tumors,  or 
a  lesion  affecting  the  nerve  after  its  exit  from  the  stylomastoid 
foramen. 

Bell's  paralysis  is  the  acquired  variety,  affecting  the  frontal  and 
inferior  branches  of  the  nerve.  It  is  due  to  any  one  of  the  several 
causes  of  neuritis  (pressure,  injury,  etc.),  or  may  occur  in  conse- 
quence of  middle  ear  disease,  in  which  instance  it  is  of  serious  im- 
port, indicating  an  extensive  involvement  of  the  temporal  bone. 

The  prognosis  is  closely  associated  with  the  cause,  motor  paraly- 
sis from  injury,  but  with  no  complications,  usually  clearing  up 
rapidly  (weeks),  and  aural  cases  making  more  or  less  complete 
recoveries  unless  there  is  necrosis  of  the  canal,  in  which  case  re- 
covery is  rare. 


SYMPATHETIC    NERVE    PARALYSIS  319 

The  treatment  is  by  persistent  galvanism  and  in  the  permanent 
cases  by  nerve  anastomosis. 


SYMPATHETIC  NERVE  PARALYSIS 

There  may  be  several  conditions  in  and  about  the  neck  that  act 
upon  the  sympathetic  nerve  and  thereby  cause  paralysis.  Some  of 
these  conditions  are  undue  pressure  from  enlarged  glands,  injury 
(operative  or  other),  disease  of  the  spinal  cord,  injury  to  the 
brachial  plexus,  etc. 

In  consequence  of  the  paralysis  there  may  be  pupillary  contrac- 
tion, and  associated  with  this  there  is  commonly  a  contracture  of 
the  eyelids,  so  that  the  whole  palpebral  aperture  seems  much 
smaller.  At  times  there  are  retraction  of  the  eyeball  and  an  ab- 
normal deficiency  in  the  production  of  perspiration  on  the  affected 
side  of  the  face. 

However,  if  the  acting  cause  is  less  severe,  so  that  in  place  of 
paralysis  there  is  irritation,  it  is  common  to  observe  pupillary 
dilatation  with  enlargement  of  the  palpebral  aperture,  and,  not  in- 
frequently, protrusion  of  the  eyeball  and  an  abnormal  production  of 
perspiration  upon  the  affected  side  of  the  face. 


CHAPTER  XLIII 

TUMORS    IN   CHILDREN 

GENERAL  CONSIDERATION  OF  TUMORS 

It  was  customary  for  a  long  time  to  call  all  swellings  tumors, 
and  so  we  have  had  grouped  together  a  conglomerate  mass  of  morbid 
conditions  which  has  resulted  in  the  utmost  confusion.  Even  with 
the  aid  of  recent  microscopic  work  and  differential  staining  the 
chaos  is  not  entirely  cleared  up  and  we  are  still  compelled  to  retain 
the  term  "tumor"  for  clinical  reasons,  although  the  pathologist  has 
bared  it  of  much  of  its  former  importance  and  significance. 

Every  advance  in  the  pathological  study  of  tumors  has  been  the 
means  of  reducing  the  list  of  morbid  conditions  classed  formerly  as 
tumors,  and,  further  than  that,  has  usually  been  the  instrument  of 
classing  under  one  term  a  number  of  conditions  which  previously 
were  considered  as  very  diverse.  Being  ignorant  of  the  patho- 
genesis  of  tumors  we  have  been  compelled  to  study  and  classify 
them  histologically. 

There  is  no  need  of  our  entering  a  discussion  as  to  the  value  of 
the  theory  of  infectious  or  parasitic  etiology,  or  of  the  part  that 
local  irritation  possibly  plays  either  in  the  production  of  a  tumor 
or  the  change  from  innocence  into  malignancy. 

With  our  present  knowledge,  it  is  sufficient  to  say  that  patholo- 
gists  have  clearly  demonstrated  that  a  tumor  is  composed  of  tissues 
which  exist  normally  in  the  body  and  that  the  minuter  structure 
of  every  tumor  corresponds  with  that  of  the  tissue  from  which  it 
grew,  as  far  as  the  tissue  itself  is  concerned;  so  that  a  fatty  tumor 

320 


THE    TRANSFORMATION    OF    TUMORS  321 

always  arises  from  fat,  etc.,  etc.  Thus,  knowing  the  minuter  struc- 
ture of  an  organ  or  part,  the  pathologist  is  enabled  to  predict  just 
what  tumors  can  affect  any  given  organ  of  the  body. 

The  division  into  benign  (or  innocent)  and  malignant  tumors  is 
the  result  of  the  previous  observations  that  some  tumors  showed  no 
destructive  features,  while  others  (the  malignant)  exhibited  the 
more  or  less  early  characteristic  of  being  very  destructive  to  the 
life  of  the  affected  individual. 

However,  we  must  be  mindful  of  the  fact  that  even  benign 
tumors  may  destroy  the  life  of  a  child,  depending  upon  the  situation 
of  such  a  tumor  and  its  ability  to  interfere  with  the  perfect  func- 
tioning of  an  important  organ.  In  this  manner  the  benign  tumors 
differ  materially  from  the  malignant  tumors,  for  the  latter  destroy 
life  no  matter  what  their  situation. 

There  are  in  addition  some  anatomic  conditions  which  differen- 
tiate innocent  from  malignant  tumors.  The  benign  or  innocent 
form  usually  has  about  it  an  investing  envelope  which  is  known  as 
its  capsule  and  through  the  agency  of  this  capsule  it  is  quite 
definitely  isolated  from  neighboring  structures  and  even  from  the 
tissue  in  which  they  grow.  Benign  tumors  do  not  infect  the 
lymphatic  glands  and  rarely  cause  death,  except  as  they  are  in  close 
relation  to  vital  structures.  The  removal  of  the  growth  is  not  fol- 
lowed by  a  recurrence,  provided  such  removal  has  been  complete. 

On  the  other  hand,  malignant  tumors  are  rarely  encapsulated 
and  show  a  very  marked  tendency  to  infiltrate  the  adjacent  tissues. 
They  infect  the  lymph  glands  and  also  have  the  property  of  dis- 
semination by  blood  vessels  or  lymphatics.  Their  removal  does  not 
secure  protection  against  recurrence,  no  matter  how  complete  the 
procedure  may  be. 

THE    TRANSFORMATION    OF    BENIGN    INTO    MALIGNANT 

TUMORS 

There  are  almost  innumerable  theories  which  might  be  advanced 
in  regard  to  this  question,  many  of  which  are  very  plausible  but 
incapable  of  direct  proof,  and,  in  a  work  of  this  character,  where 


322  TUMORS  IN  CHILDREN 

the  practical  is  made  to  predominate  over  the  purely  theoretical, 
we  may  well  dismiss  these  without  discussion.  Of  this  we  are 
certain :  that  the  more  the  histology  of  all  tumors  is  carefully  studied 
and  advanced,  the  less  the  line  of  demarcation  between  the  benign 
and  the  malignant  tumors  becomes.  With  our  present  knowledge 
upon  this  question,  we  are  no  doubt  justified  in  making  the  distinc- 
tion of  benign  and  malignant  tumors,  but  when  it  comes  to  a  ques- 
tion of  real  practical  value,  the  question  of  prognosis  or  of  treat- 
ment, our  division  is  much  less  significant. 

Face  to  face  with  the  great  uncertainty  which  enshrouds  the 
whole  question,  the  position  of  the  pathologist  is  made  very  strong 
by  the  attitude  of  the  practice  of  the  surgeon,  who,  in  his  dealing 
with  them,  takes  the  stand  that  all  tumors,  whether  benign  or  malig- 
nant, or  occupying  an  indeterminable  middle  ground,  should  be  re- 
moved at  the  earliest  possible  moment  if  the  circumstances  permit. 
Such  a  position  and  stand  is  good  practice  in  the  face  of  all  the 
facts  and  theories  which  we  possess  upon  the  subject. 


VARIETIES  OF  TUMORS 

Fibromata. — It  was  formerly  supposed  that  fibromata  were  very 
common,  but  pathology  has  proven  that  tumors  that  are  composed 
entirely  of  fibrous  tissues  are  comparatively  rare.  However,  there 
are  mixed  varieties  which  are  common  enough  in  childhood.  Such 
tumors  may  occur  in  any  situation  in  which  connective  tissue  is 
abundant.  For  instance,  pigmental  moles  are  fibromata.  Fibromata 
may  be  single  or  occur  as  numerous,  small,  painless  nodules  in  the 
connective  tissue  and  lying  directly  beneath  the  skin.  Less  com- 
monly they  occur  as  small  enlargements  along  some  nerve  trunk. 
There  is  one  variety  that  is  very  painful. 

Occasionally  they  are  found  growing  in  the  nasopharynx.  Fibro- 
angioma  and  fibrosarcoma  are  not  uncommonly  observed  in  the  naso- 
pharynx of  children  over  the  age  of  eight  to  ten  years  and  especially 
in  males.  The  so-called  fibrous  epulis,  a  small,  dense,  smooth  tumor, 
which  grows  from  the  periosteum  of  the  alveolar  process,  is  an 


VARIETIES    OF    TUMORS  323 

example  of  a  misnomer,  for  the  name  has  no  significance  in  fact, 
except  as  it  relates  to  the  situation  of  the  tumor.  These  tumors 
must  be  distinguished  from  the  fibroma,  which  comes  from  the  con- 
nective tissue  of  the  alveolar  process,  and  which  latter  requires  the 
use  of  chisel  or  saw  for  its  removal. 

Keloid  is  one  variety  of  fibroma, 

The  ETIOLOGY  of  this  class  of  tumors  seems  to  be  irritation  or 
trauma.  The  instances  in  which  they  occur  congenitally  are  com- 
paratively rare.  This  etiology  probably  explains  in  a  large  measure 
why  they  are  less  common  in  children  than  in  adnlt  life.  The  diag- 
nosis is  made  from  the  situation  and  character  of  the  tumor.  It  is 
smooth  in  outline  and  easily  movable  on  account  of  being  encap- 
sulated. The  growth  of  the  tumor  is  very  slow  and  is  accompanied 
by  no  pain  unless  directly  connected  with  a  nerve  or  pressing  upon 
one.  Outside  of  this  pain  is  only  present  if  the  tumor  is  markedly 
inflamed.  The  skin  covering  a  fibroma  is  usually  thinned  out  and 
smooth,  and  this  characteristic  helps  to  distinguish  it  from  papil- 
loma,  which  is  covered  by  adherent  skin. 

The  PROGNOSIS  depends  materially  upon  the  situation  of  the 
tumor,  for  it  is  harmless  unless  pressing  upon  some  important 
organ  or  nerve  trunk  or  occluding  a  passage.  Irritation  and  injury 
add  another  danger :  that  of  transformation  into  a  sarcoma,  although 
it  may  do  this  irrespective  of  either  of  these  elements. 

The  TREATMENT  should  always  be  removal,  if  the  tumor  is  ac- 
cessible. This  is  necessary  because  of  the  great  and  constant  danger 
of  injury  or  irritation  and  final  transformation  into  a  sarcoma. 
Naturally  the  situation  of  the  tumor  becomes  a  factor  in  the  sim- 
plicity of  its  removal,  and,  if  deep  seated,  the  operative  procedure 
may  be  a  somewhat  extended  one.  Being  encapsulated,  the  pro- 
cedure is  one  of  enucleation  unless  there  is  present  some  inflamma- 
tion which  requires  the  more  radical  step  of  excision. 

Myxomata. — These  tumors  have  a  composition  which  is  identical 
with  the  jelly-like  substance  of  the  umbilical  cord.  The  so-called 
"auditory  or  aural  polypi"  must  not  be  considered  as  tumors,  for 
they  merely  consist  of  myxomatous  tissue.  The  commonest  variety  is 
that  which  occurs  at  the  umbilicus  of  the  infant ;  the  so-called  fungus 


324  TUMOKS  IN   CH1LDKBN 

umbilici  or  umbilical  polypus,  and  which  usually  appears  as  a  much 
reddened  pea  or  cherry-sized  growth. 

While  it  would  be  strictly  within  our  province  to  rule  out 
myxoma  entirely  from  our  classification  of  tumors,  it  is  probably 
better  to  retain  the  same  for  a  time  to  avoid  confusion.  Therefore 
we  will  describe  some  of  the  variety  of  tumors  which  have  been  con- 
sidered as  myxoma.  For  instance,  polypus  of  the  rectum  is  really 
a  soft  vascular  myxofibroma  attached  to  the  wall  of  the  rectum  by 
a  pedicle.  Such  a  growth  may  appear  outside  of  the  sphincter  dur- 
ing defecation  or  may  only  be  detected  high  in  the  rectum  by  digital 
examination.  It  usually  causes  symptoms  of  pain  upon  defecation 
or  tenesmus;  blood-stained  stools  or  an  oozing  of  bloody  mucus  and 
perhaps  reflex  bladder  symptoms  from  pulling  of  the  growth.  Ker- 
vous  symptoms  are  common  on  account  of  the  local  irritation. 
When  multiple,  rectal  polypi  are  always  invariably  adenomata. 

Myxolipoma,  teratoma,  and  myxosarcoma  are  considered  under 
their  appropriate  headings. 

There  is  a  great  tendency  in  so-called  myomata  to  transforma- 
tion into  sarcoma,  although  in  itself  it  is  very  benign.  The  growth 
is  slow  and  any  rapid  development  should  at  once  arouse  the  suspi- 
cion of  malignancy.  It  is  soft,  fluctuating,  and  translucent. 

TREATMENT. — Removal  is  the  only  treatment  and  the  stump 
should  be  carefully  cauterized.  It  is  the  part  of  wisdom,  in  every 
instance  in  which  the  tumor  takes  on  a  sudden  growth,  to  remove  it 
immediately  and  take  liberal  sections  of  it  to  determine  microscop- 
ically whether  or  not  the  transition  is  taking  place. 

In  rectal  polypi,  avulsion  has  been  tried  by  many  and  by  a  few 
with  apparent  success,  but  we  cannot  recommend  such  a  procedure, 
for  the  dangers  of  hemorrhage  are  great,  and  incomplete  removal  is 
the  final  result  except  in  the  most  skillful  hands. 

Ligature  close  to  the  base  and  incision  close  to  the  ligature  is 
tho  most  desirable  procedure. 

When  situated  in  the  nares  or  the  aural  canal,  the  forceps,  the 
snare,  or  the  sharp  spoon  curette  are  to  be  used,  but  always  with 
the  precaution  that  the  removal  is  complete  so  as  to  avoid  any 
recurrence.  Whenever  possible  the  basal  attachment  should  be  re- 


VAKIETIES    OF    TUMOES  325 

moved  and  the  work  of  the  instrument  supplemented  by  the  use  of 
the  cautery. 

Lipoma. — This  is  the  most  innocent  of  all  the  tumors  and  also 
one  of  the  rarest  of  childhood.  Its  only  danger  comes  from  its  size 
and,  at  times,  from  its  position.  When  it  is  stated  that  it  is  a  rare 
tumor  in  children  it  must  be  remembered  that  reference  is  made 
to  pure  lipoma  and  not  to  the  more  common  mixed  types,  as  when 
associated  with  muscular,  fibrous,  cartilaginous,  and  bone  struc- 
tures. 

Occasionally  we  will  observe,  as  in  cretins,  a  more  or  less  general 
fat  hypertrophy  or  fatty  enlargements  about  the  neck,  and  these  de- 
posits have  been  called  lipomas,  and  pseudolipomas,  as  well  as  dif- 
fuse lipomata.  They  can  in  no  sense  be  considered  as  tumors. 

The  TREATMENT  of  lipoma  is  by  excision.  The  treatment  of 
combination  tumors  in  which  lipoma  is  a  part  is  a  different  mat- 
ter, and  this  is  considered  under  the  appropriate  headings. 

The  general  hypertrophy  of  fat  or  "lipomatosis"  and  the  fatty 
enlargements  which  occur  in  cretins  are  always  treated  medically, 
for  there  is  no  appropriate  surgical  treatment. 

Bone  Tumors. — The  clinical  history  of  a  child  suffering  from 
some  form  of  bone  tumor  is  in  most  instances  as  follows :  ( 1 )  There 
has  been  some  pain  or  tenderness  over  the  affected  area  for  several 
weeks  or  perhaps  months,  or  an  occasional  limping  accompanied  by 
or  alternating  with  periods  of  pain;  (2)  a  distinct  tumor  is  felt 
when  the  physical  examination  is  made;  (3)  a  very  slight  trauma 
has  been  the  direct  cause  of  a  fracture. 

Either  one  of  these  should  make  the  surgeon  suspicious  of  tumor 
in  the  bone.  But  in  the  examination  we  must  determine  whether 
the  enlargement,  which  is  palpable,  is  actually  a  neoplasm  of  the 
bone  or  merely  the  result  of  some  inflammatory  process.  Having 
determined  this  differential  point,  it  is  necessary  to  definitely  de- 
termine whether  the  tumor  is  benign  or  malignant.  If  the  child 
is  brought  for  examination  on  account  of  a  fracture  from  slight 
trauma,  we  must  eliminate  carefully  the  possible  existence  of  the 
several  causes  of  such.  Therefore  it  is  necessary  to  exclude  spon- 
taneous fracture  (or  that  due  to  slight  trauma)  due  to  scurvy, 


32fi  TUMORS  IN   CHILDREN 

rachitis,  and  exhausting  nutritional  diseases,  also  infectious  osteo- 
myelitis, tuberculosis  of  bone,  and  syphilis.  With  these  excluded, 
if  the  fracture  has  been  due  to  rarefaction  of  the  bone  by  the  tumor, 
then,  added  to  the  suggestive  history  and  the  palpable  enlargement, 
will  be  the  more  or  less  characteristic  history  and  symptoms  of 
bone  neoplasms. 

If  the  child  exhibits  palpable  enlargement  of  the  bone,  palpation 
usually  shows  many  soft  spots  and  the  enlargement  is  seldom  uni- 
formly firm. 

Chondromata. — Chondromata  are  tumors  formed  of  hyalin  cartil- 
age and  the  outgrowths  of  preexisting  cartilage.  Of  the  innocent 
growths  of  childhood  these  are  by  far  the  most  common. 

The  ETIOLOGY  is  not  quite  clear,  although  the  influences  of 
heredity  are  very  marked  in  some  instances.  Trauma  plays  an  im- 
portant part  in  the  etiology,  but  whether  it  does  so  independent  of 
heredity  is  uncertain.  Rachitis  certainly  predisposes  the  child  to 
chondromata,  and  it  would  seem  from  the  history  of  some  cases  a& 
though  this  disease  was  not  alone  a  predisposing  but  an  actual 
factor. 

OCCURRENCE. — The  phalanges  seem  to  be  a  favorite  situation 
for  chondromata,  and  several  fingers  of  one  or  of  both  hands  may 
be  badly  distorted  by  the  growths.  Chondromata  of  bone  make 
their  appearance  practically  always  before  puberty.  Being  strongly 
encapsulated  they  very  often  create  deep  furrows  in  the  bones 
affected. 

PATHOLOGY. — Chondromata  are  hard  and  painless  as  a  rule,  but 
these  factors  may  be  modified  to  the  extent  that  occasionally  the 
tumor  will  become  cystic  upon  its  surface  and  may  cause  pain  by 
direct  pressure  upon  a  nerve.  As  a  rule  they  grow  slowly  and 
steadily.  It  is  this  slow  but  steady  growth  and  the  fact  that  chon- 
dromata are  multiple  that  distinguish  them  from  osteosarcoma.  The 
growth  is  encapsulated  unless  mixed.  In  cases  of  doubt,  if  a  needle 
is  plunged  into  an  osteoma  it  will  not  enter  the  unyielding  mass, 
but  with  chondromata  the  needle  enters  quite  freely.  Malignant 
chondromata  is  the  term  applied  to  sarcomata  in  which  there  is 
an  abundance  of  hyalin  cartilage  and  which  latter  has  become 


calcified,  and  the  differences  between  this  and  the  benign  variety 
of  chondromata  must  be  remembered.  The  prognosis  is  only  un- 
favorable as  the  liability  of  the  growth  to  become  a  sarcoma  is 
evidenced. 

The  TREATMENT  is  removal  whenever  possible.  But  the  situa- 
tion and  extent  of  the  growth  may  make  this  a  difficult  matter.  It 
is  necessary  to  remember,  in  deciding  npon  an  operative  procedure 
or  making  the  prognosis,  that  chondromata  of  bone  generally  stop 
increasing  in  size  as  the  skeleton  reaches  its  full  growth.  When 
operative  procedure  becomes  necessary  the  best  surgical  relief  is 
obtained  by  incision  of  the  shell  and  capsule  and  shelling  out  of 
the  cartilage.  The  fact  that  the  tumor  is  encapsulated  has  been 
responsible  for  the  more  conservative  surgical  work  upon  these 
tumors  during  the  past  few  years.  If  sufficient  time  is  given  to 
careful  surgical  work  it  is  remarkable  how  much  bone  can  be  spared 
in  the  removal  of  the  tumor,  even  when  of  considerable  size.  But, 
despite  this,  there  are  times  when  the  more  radical  procedures  are 
forced  upon  us.  The  most  trying  cases  to  relieve  by  operation  are 
those  in  which  a  joint  is  involved,  for,  no  matter  how  carefully 
planned,  excision  results  almost  invariably  in  a  badly  stumped  joint- 
When  there  is  considerable  involvement  of  joint,  amputation  may 
have  to  be  considered  as  the  best  means  of  relief.  When  the  interior 
of  a  bone  is  involved  the  operative  procedure  must  involve  com- 
plete excision  of  the  infected  parts.  It  is  in  the  cases  in  which 
the  whole  thickness  of  the  shaft  of  a  bone  is  involved  that  amputa- 
tion becomes  most  necessary. 

Chondromata  affecting  the  parotid  gland  usually  cease  increas- 
ing after  attaining  a  considerable  size.  The  treatment  of  this 
variety  is  complete  enucleation,  which  may  be  done  at  any  period 
of  its  growth.  Great  care  must  be  exercised  to  avoid  injury  to 
the  facial  nerve,  the  blood  vessels,  or  the  duct  of  the  gland. 

Osteomata. — VARIETIES. — Osteomata  are  tumors  composed  of 
bone  and  are  of  two  varieties :  compact  and  cancellous.  The  com- 
pact or  hard  osteoma  is  identical  in  its  structure  with  the  tissue 
forming  the  hard  portion  of  the  shafts  of  the  long  bones.  The 
cancellous  or  soft  varietv  resembles  in  its  structure  the  cancellous 


328  TUMORS  IN  CHILDREN 

portions  of  the  bones  and  possesses  a  thick  covering  of  hyaliu 
cartilage. 

OCCURRENCE. — These  tumors  occur  with  quite  some  frequency 
during  childhood,  and  this  is  not  difficult  to  understand  when  we 
recall  the  rapid  changes  which  are  taking  place  in  the  skeleton  dur- 
ing this  period  of  development  and  growth.  And  the  fact  that  all 
bony  growth  is  most  active  at  or  near  to  the  epiphyseal  line  makes 
their  occurrence  at  this  point  most  common. 

DIAGNOSIS. — Chondromata  and  osteomata  have  much  between 
them  that  is  common  and  the  resemblance  is  so  striking  at  times  that 
a  clear  demarcation  is  impossible.  This  resemblance  is  much  more 
marked  when  there  occurs  a  mixture  of  varieties,  or  a  transition  is 
taking  place,  as  not  uncommonly  occurs.  As  in  chondromata,  the 
influence  of  heredity  is  marked,  especially  when  favored  by  the 
active  factors  of  injury  or  irritation.  The  growths  are  mostly 
multiple  and  very  slow  of  growth.  When  the  child's  skeleton  has 
attained  its  maximum  growth  the  tumor  usually  ceases  increasing 
in  size  also.  The  hereditary  influence  is  also  shown  in  the  rather 
common  instances  in  which  more  than  one  member  of  a  family  will 
be  affected. 

Cartilage-clad  osteomata  are  occasionally  observed  in  large  num- 
bers on  the  long  bones  of  the  arms  and  legs  and  may  be  congenital, 
frequently  exhibiting  bilateral  symmetry.  Their  recognition  is 
usually  very  easy  on  account  of  the  extreme  hardness  and  the  fact 
that  the  growth  is  situated  about  the  bone.  The  X-ray  also  helps 
materially  in  outlining  their  situation  and  attachments.  In  their 
development  the  tumors  are  painless  unless  they  involve  some  nerve 
structure.  If  unmixed,  osteomata  are  innocent. 

Care  must  be  exercised  not  to  mistake  osteomata  for  exostosis. 
This  latter  term  has  recently  been  restricted  to  include  only  such 
enlargements  as  occur  in  bone  at  the  point  of  the  insertion  of  a 
muscle.  For  instance,  if  the  long  bones  of  a  very  young  child  are 
examined  it  will  be  found  that  they  are  smooth  in  outline  and  the 
shape  almost  cylindrical.  The  attachment  of  the  powerful  muscles 
is  to  periosteum,  which  is  relatively  thick.  On  the  other  hand,  in 
the  adult  the  shafts  of  the  long  bones  are  irregular  and  at  the  i 


tion  of  the  more  powerful  muscles  there  is  an  enlargement,  and  this 
ossified  insertion  of  the  muscle  may  be  easily  felt  through  the  soft 
parts. 

TREATMENT. — Surgical  interference  is  usually  unnecessary  and 
is  only  indicated  when  the  tumor  occasions  pressure  over  some  im- 
portant part,  or  interferes  with  the  perfect  functioning  of  an  organ 
or  joint.  Deformity  of  the  face  from  involvement  of  its  bones,  or 
deafness,  which  was  occasioned  by  interference  with  the  auditory 
canal,  would  be  added  indications  for  operation. 

The  sessile  osteomata  are  sometimes  very  difficult  to  remove  on 
account  of  their  firmness,  while  the  pedunculated  variety  may  often 
be  readily  removed  with  stout  forceps.  When  situated  near  a  joint, 
the  operative  procedure  must  take  cognizance  of  the  fact  of  the 
danger  involved  in  opening  into  the  synovial  membrane. 

A  radical  removal  of  the  growth  prevents  any  recurrence. 
Myomata. — Tumors  composed  of  striated  muscular  fibers   (rhab- 
domyoma)  are  rare  enough  to  be  considered  as  pathological  curios- 
ities, and  when  it  does  occur  it  is  always  congenital. 

There  can  be  little  question  but  that  many  of  the  tumors  which 
were  formerly  reported  as  myoma  were  in  reality  some  other  type 
of  growth,  most  likely  sarcoma,  and  this  was  made  possible  by  the 
great  difficulty  in  recognition. 

In  the  reported  cases,  the  occurrence  of  the  tumor  has  been 
usually  in  connection  with  the  kidney  or  testicle.  Myoma  and  myo- 
fibroma  have  been  reported  in  the  cardiac  musculature.  In  vesical 
polypus,  and  in  tumors  of  the  parotid  and  testicle  and  ovary,  striated 
muscular  fibers  have  been  found  by  different  observers. 

Leiomyoma,  composed  of  the  unstriated  muscular  fibers,  rarely 
occurs  during  childhood. 

Neuromata. — There  has  not  been  until  recently  a  very  clear 
understanding  of  what  constituted  neuromata,  for  with  former 
classifications  all  tumors  of  nerves  were  called  neuromata  by  the 
surgeons,  but  not  by  the  pathologists. 

This  uncertainty  has  been  particularly  true  of  children,  and 
Ashby  and  Wright  report  the  instance  of  an  eleven-year-old  female 
who  was  operated  upon  for  neuroma.  The  tumor  and  the  nerve 


330  TUMORS  IN  CHILDREN 

could  not  be  separated  and  about  five  inches  of  the  latter  was  re- 
moved, but  the  result  was  a  good  one,  with  sensation  retained  in 
the  foot.  The  pathologist's  report  showed  this  growth  to  be  a 
myxofibroma  with  nerves  which  could  be  traced  through  it  for  a 
distance,  and  which  then  became  lost  as  they  showed  signs  of  de- 
generation. This  is  merely  an  illustration  of  what  has  formerly 
taken  place,  and  such  a  tumor,  not  carefully  examined,  would  be 
put  down  as  a  neuroma.  If  we  could  carefully  eliminate  from  the 
reported  cases  all  those  of  fibromas  or  myxomas,  connected  with 
nerves  very  closely,  and  all  instances  of  bulbous  tumor  which  are 
traversed  by  nerves  or  nerve  filaments,  we  would  at  once  eliminate 
many  so-called  neuromas. 

The  somewhat  familiar  swelling  to  which  the  name  neuroma  is 
applied  is  an  oval  encapsulated  tumor  composed  of  tissue  which  is 
exactly  similar  to  that  which  composes  the  nerve  sheath.  Such 
tumors  may  be  single  or  multiple.  Pain  is  not  a  necessary  feature, 
although  when  one  of  these  tumors  is  situated  upon  the  terminal 
filaments  of  a  cutaneous  nerve  it  gives  rise  to  considerable  pain. 
Xeuromas  may  be  situated  upon  any  portion  of  a  nerve  and  may 
vary  in  size  from  a  pin-head  to  a  good-sized  lemon. 

Most  commonly  the  side  of  the  face  is  the  site  of  neuroma,  and 
in  these  parts  they  are  easily  felt  beneath  the  skin.  While  they 
rarely  recur  or  disseminate,  they  may,  in  exceptional  cases,  cause 
death.  In  itself  an  innocent  tumor,  neuroma  may  be  transformed 
into  sarcoma.  Irrespective  of  this  danger  it  may  seriously  inter- 
fere with  the  child's  activity  and  therefore  its  health  and  develop- 
ment. 

The  TREATMENT  of  a  solitary  neuroma  which  lies  in  a  part  easily 
accessible  is  by  removal  if  it  is  giving  any  marked  inconvenience. 
On  general  principles  if  the  neuroma  is  causing  but  little  or  no 
distress  or  interfering  with  no  function,  it  may  be  left  alone. 
There  is  always  a  danger  in  removal  that  the  tumor  will  be  found 
to  be  situated  on  an  important  nerve  trunk  containing  motor  fibers, 
and  destruction  of  these  may  prove  more  serious  than  the  mere 
presence  of  the  tumor  itself. 

The  most  satisfactory  procedure  is  to  disregard  the  growth  until 


VARIETIES    OF   TUMORS  331 

the  symptoms  produced  by  it  become  insistent  for  relief,  and  then 
the  operative  procedure  should  be  planned  to  enucleate  the  tumor 
if  possible,  so  as  to  avoid  all  injury  to  the  nerve. 

Lymphoma. — Enlargement  of  the  lymphatic  glands  is  probably 
the  most  common  of  all  varieties  of  tumefaction,  and  yet  there  exists 
considerable  confusion  in  regard  to  lymphoma.  Very  common 
causes  of  the  enlargement  are  acute  and  chronic  simple  adenitis, 
tuberculous  adenitis.  For  a  detailed  consideration  of  these,  the 
reader  is  referred  to  the  section  on  Adenitis. 

The  association  of  enlargement  with  leukemia  and  pseudo- 
leukemia,  although  somewhat  obscure  in  its  nature,  is  less  common 
and  yet  a  frequent  occurrence.  Carcinoma  might  in  more  rare  in- 
stances be  a  cause  of  enlargement  (secondary).  More  remote  still 
would  be  glanders  acting  as  a  cause  of  enlargement. 

The  true  lymphoma  is  a  benign  encapsulated  tumor  composed 
of  new  lymphatic  tissue.  The  enlargement  is  due  to  this  new  tissue 
and  does  not  in  any  manner  depend  upon  blood  infection.  The  sur- 
rounding tissues  and  glands  are  not  involved.  The  tumor  is  mov- 
able and  smooth  in  its  outline  and  usually  single,  but  when  several 
appear  at  the  same  time  they  show  a  remarkable  uniformity  of 
growth  and  development.  The  tumor  grows  very  slowly  and  does 
not  at  any  period  of  its  development  exhibit  any  signs  of  heat,  pain, 
redness,  or  tenderness. 

There  is  but  one  line  of  TREATMENT  and  that  is :  early  and  com- 
plete enucleation. 

Sarcoma. — When  sarcoma  occurs  in  childhood,  it  is  much  more 
malignant  than  in  adult  life,  growing  much  more  rapidly  and  pro- 
ducing a  more  destructive  effect  upon  the  general  health.  On  the 
other  hand,  it  is  not  so  common  in  children  as  in  adults.  Sarcoma 
is  practically  the  only  malignant  tumor  of  childhood.  The  tumor 
may  arise  from  any  situation  in  which  connective  tissue  exists,  and 
in  studying  the  pathology  of  these  growths  it  is  important  to  re- 
member that  when  they  involve  any  organ  the  original  site  of  the 
growth  was  in  the  connective  tissue  about  or  connected  with  the 
organ  and  from  there  the  encroachment  took  place. 

VARIETIES. — There  are  several  varieties  of  sarcoma  and  these 


332 


TUMORS  IN  CHILDREN 


derive  their  names  from  the  prevailing  type  of  cell  which  is  in  their 
composition.  Therefore  we  find  that  the  "round-cell  sarcoma"  con- 
sists almost  entirely  of  round  cells,  each  with  a  central  round 
nucleus.  A  very  delicate  intercellular  substance  separates  the  cells 
of  the  tumor  and  it  is  rich  in  blood  vessels  and  devoid  of  lymph- 
atics. This  richness  in  blood  supply  is  sometimes  so  marked  that 
the  tumor  will  pulsate  and  the  movement  in  the  tumor  may  be 

detected  by  observation  as  well  as  by 
palpation.  Occasionally  a  distinct 
hum  or  murmur  may  be  heard  through 
the  tumor.  These  points  are  some- 
times valuable  ones  for  differentiation. 
This  type  may  occur  in  bone,  nerve, 
muscle,  gland,  or  any  organ  at  any 
time  of  life,  either  intrauterine  or  ex- 
trauterine. 

A  rather  common  type  of  this 
round-cell  variety  is  one  that  occurs 
with  the  lymph  gland  tissue  in  abun- 
dance and  from  this  feature  derives 
the  name  of  "lymphosarcoma."  The 
round-cell  sarcoma  is  the  most  malig- 
nant of  all  types.  "The  spindle-cell 
sarcoma"  has  cells  which  resemble 
spindles,  which  are  usually  of  a  uni- 
form size.  In  different  tumors  the 
size  and  shape  of  the  cells  will  differ 
very  materially,  although  each  indi- 
vidual tumor  shows  marked  uniformity 
of  cells.  If  the  tumor  contains  much 
hyalin  cartilage,  as  it  may  when  situ- 
ated on  the  shafts  of  the  long  bones,  it  is  often  referred  to  as  a 
"chondrifying  sarcoma."  Sometimes  the  hyalin  cartilage  may  com- 
pose most  of  the  tumor.  If  this  cartilage  is  calcified  it  is  often  re- 
ferred to  as  "malignant  chondroma,"  and  the  differences  between 
this  and  the  benign  chondromata  must  be  appreciated.  The  spindle- 


FIG.  111. — SARCOMA  OF  THE  KID- 
NEYS. 

Tumors  are  outlined  to  show  size. 
(Napier.) 


VARIETIES    OF    TUMORS  333 

celled  sarcoma  is  second  in  its  malignancy  in  childhood  and  usually 
springs  from  bone,  periosteum,  or  fascia. 

The  "giant-celled  sarcoma"  is  the  least  malignant  of  the  three 
varieties.  It  occurs  most  commonly  upon  the  articular  ends  of  the 
long  bones  and  upon  the  jaw.  While  the  recognition  of  these  three 
varieties  is  necessary,  still  there  are  characteristics  which  are  quite 
common  to  all  that  may  well  be  considered. 

PATHOLOGY. — Sarcomata  rarely  are  encapsulated  and  when  such 
a  condition  is  present  it  is  really  only  apparent  and  is  consequent 
upon  the  location  of  the  tumor.  Lacking  the  capsule  the  tumor  in- 
filtrates the  adjoining  structures.  This  becomes  a  very  serious  mat- 
ter when  the  situation  is  one  in  which  important  organs  or  tissues 


FIG.  112. — SARCOMA  OF  THE  KIDNEYS.     (Napier.)     Tumors  outlined. 

are  involved.  In  this  invasion  infiltration  no  structure  is  spared 
and,  when  dangerously  situated,  even  a  very  small  growth  may  be 
destructive  to  the  child's  life.  This  characteristic  also  has  a  very 
important  bearing  upon  the  treatment  because  anything  short  of 
the  most  radical  operative  procedure  and  excision  wide  of  the 
growth  will  result  in  recurrence. 

Most  important,  too,  is  the  ease  with  which  cells  from  the 
original  tumor  are  carried  by  the  blood  vessels  to  distant  parts, 
where  they  become  arrested  in  their  progress  in  the  smaller  vessels 
or  find  a  suitable  grafting  place  and  set  up  secondary  processes. 
Tie  number  of  such  may  be  unlimited.  This  widespread  dissemina- 
tion is  one  of  the  most  serious  and  dangerous  features  of  sarcomata. 


334  TUMORS  IN  CHILDREN 

OCCURRENCE. — While  sarcoma  is  entirely  unlimited  in  its  situa- 
tion and  respects  no  age,  yet  there  are  some  -interesting  facts  in 
regard  to  its  distribution  and  the  age  incidence.  For  instance,  in 
infancy,  the  kidneys,  the  ovaries,  and  the  adrenals  are  very  liable 
to  become  the  site  of  sarcoma  and  in  a  large  number  of  instances 
this  occurrence  is  bilateral.  On  the  other  hand,  if  the  tumor  occurs 
in  these  situations  in  adults,  it  is  unilateral.  And  again,  during 
infancy,  retinal  sarcomata  are  not  uncommon  and  these  possess  the 
ability  to  disseminate  through  the  optic  nerve,  but  restricted  to 
it  entirely  and  most  commonly  occur  bilaterally.  However,  if 
occurring  in  an  adult  in  this  situation,  the  tumor  is  unilateral  and 
has  a  very  widespread  dissemination,  sometimes  throughout  the 
body.  Sarcomata  rarely  attack  either  the  radius  or  the  ulna  and 
even  the  fibula  usually  escapes.  It  is  a  curious  fact  that  when  the 
tibia  is  the  point  of  attack  the  growth  is  not  so  malignant  and  recur- 
rence after  amputation  is  always  longer  delayed  than  when  the 
femur,  for  instance,  is  the  site  of  the  growth. 

By  far  the  most  common  sarcoma  in  children  is  that  of  the  kid- 
ney, while  sarcoma  of  the  testicle  holds  second  place  in  point  of 
frequency. 

CHARACTER  AND  GROWTH. — Sarcomata  are  almost  always  regu- 
lar in  their  outlines,  although  the  shape  of  the  tumor  may  be 
globular,  circular,  oblong,  or  flattened,  according  to  the  situation 
of  the  tumor  and  its  adjustment  to  adjoining  structures.  The  tumor 
is  smooth  and  if  located  in  the  soft  parts  it  is  movable.  If  covered 
by  skin  this  is  not  adherent,  but  the  veins  of  the  surface  may  be 
much  enlarged.  The  consistence  of  the  tumor  varies  very  widely, 
so  that  it  may  be  firm  or  cystic  and  the  softer  tumor  may  give  rise 
to  apparent  fluctuation.  Sometimes  the  tumor  itself  is  the  first 
thing  noted,  but  usually  before  such  an  occurrence  there  are  present 
the  symptoms  which  are  dependent  upon  pressure  of  the  growth. 
These  symptoms,  of  course,  are  as  varied  as  the  situation  of  the 
tumor  itself.  The  growth  of  a  sarcoma  is  very  rapid.  For  instance, 
in  sarcoma  of  the  kidney,  the  growth  may  be  so  rapid  that  within 
three  or  four  months  from  the  time  of  its  first  discovery  it  may 
fill  the  abdomen  of  the  child.  Such  a  tumor  may  at  first  be  mis- 


VAEIETIES    OF    TUMORS 


335 


taken  for  hydronephrosis  and  exploratory  puncture  may  be  neces- 
sary to  determine  this.  The  needle  is  best  inserted  half-way  be- 
tween the  last  rib  and  the  crest  of  the  ilium ;  three  inches  from  the 
spine.  Hydronephrosis  would  yield  a  urinous  fluid,  either  with  or 
without  blood. 

DIAGNOSIS. — From  carcinoma  sarcoma  is  distinguished  by  the 
latter's  more  rapid  growth,  its  later  ulceration  (unless  skin  or 
mucous  membrane  is  involved),  its  more  rapid  dissemination  along 


FlG.    113.-SARCOMATA   OF  THE   KlDNEYS,    REMOVED   FROM   A   CHILD    OF   TWO   YEARS. 

the  blood  vessels  instead  of  by  the  lymphatics,  and  its  later  con- 
stitutional symptoms,  as  cachexia,  etc. 

TREATMENT. — The  treatment  of  sarcoma  is  early  and  radical 
removal,  therefore  amputation  is  almost  invariably  indicated  if  the 
tumor  be  situated  upon  a  limb.  The  growth  of  the  tumor  is  so  very 
rapid  and  its  dissemination  through  the  blood  vessels  so  very  wide- 
spread and  rapid  that  operative  procedure  must  rapidly  follow  the 
diagnosis  of  the  growth.  In  view  of  the  fact  that  dissemination  is  so 
prominent  a  characteristic  of  these  growths,  the  incising  of  the  tis- 
sues well  beyond  the  limits  of  the  tumor  becomes  absolutely  neces- 


336  TUMORS  IN  CHILDREN 

sary  and  is  an  important  factor  in  the  prognosis.  The  neighboring 
lymphatics  must  also  be  removed  and  if  skin  covers  the  tumor  it 
must  be  excised  also  freely.  The  instances  in  which  an  apparently 
radical  operation  has  been  done  upon  a  limb  and  the  tumor  has 
recurred  are  common  enough  to  warrant  the  surgeon  performing  an 
immediate  amputation  in  such  cases  without  temporizing  and  being 
finally  forced  to  a  later  amputation. 

Of  course,  if  numerous  metastases  have  occurred,  any  operative 
procedure  may  become  useless  as  far  as  the  prolongation  of  life  is 
concerned. 

At  the  present  time,  anything  short  of  radical  surgical  inter- 
ference is  worse  than  useless. 

Carcinoma. — Carcinoma  is  not  nearly  so  common  in  childhood 
as  is  sarcoma,  and  when  it  does  occur  the  usual  form  is  that  of  an 
encephaloma.  Such  a  tumor  is  usually  soft  and  rapidly  growing 
on  account  of  the  excessive  number  of  cells  which  are  enmeshed  in 
a  rather  sparse  lattice  stroma.  The  malignancy  is  very  marked. 
The  disease  is  one  of  prime  importance,  despite  its  relative  infre- 
quency  in  children,  because  of  its  insidious  onset,  its  rapid  destruc- 
tion of  life,  and  the  helpless  and  hopeless  condition  in  which  it  leaves 
its  victim  when  the  disease  is  once  firmly  established. 

CHARACTERISTICS  AND  PATHOLOGY. — One  of  the  features  which 
makes  this  disease  so  dangerous  is  the  frequency  with  which  its 
diagnosis  is  delayed  or  not  made  until  the  invasion  has  been  such 
as  to  give  the  victim  no  chance  for  life.  The  dissemination  of  the 
tumor  by  the  formation  of  secondary  nodules  and  its  rapid  exten- 
sion to  the  lymph  glands  add  much  to  its  malignancy. 

A  striking  characteristic  of  carcinoma  is  that  it  is  never  strictly 
limited  as  a  lesion,  so  that  it  is  impossible  to  map  it  out  with  any 
degree  of  accuracy.  The  surgeon  comes  squarely  upon  this  prob- 
lem when  he  undertakes  an  operative  procedure  and  cuts  into  the 
tissues;  there  is  nothing  that  in  any  way  clearly  defines  the  limits 
of  the  growth.  Even  when  examined  by  the  pathologist  it  is  impos- 
sible to  tell  with  any  degree  of  accuracy  the  limitations  of  the 
growth.  This  characteristic  has  a  direct  bearing  upon  the  surgical 
procedure,  for,  if  the  microscope  fails  to  reveal  the  limits  of  the 


VARIETIES    OF    TUMORS  337 

tumor,  how  difficult  is  the  position  of  the  operator  who  must  depend 
largely  upon  his  unaided  sense  of  sight  and  touch.  Thus  it  is  that 
the  removal  of  the  whole  of  a  cancerous  organ  or  part  is  the  usual 
procedure  and  the  only  one  that  promises  much  result.  For  instance, 
if  a  child  is  observed  with  a  gland  affected  with  carcinoma,  it  is 
impossible  to  say  that  that  gland  alone  is  the  site  of  the  disease ; 
carcinoma  very  rapidly  invades  surrounding  structures  and  it  makes 
no  difference  what  the  nature  of  the  surrounding  tissue.  This  im- 
plication of  adjacent  parts  is  such  a  grave  matter  that  we  must 
always  consider  it  in  planning  any  operative  procedure.  Carcinoma 
is  poorly  supplied  with  blood  and,  therefore,  degenerative  changes 
are  early  and  common.  This  feature  helps  us  in  distinguishing  it 
from  sarcoma. 

The  infection  of  the  lymph  glands  by  carcinoma  is,  as  has  been 
stated,  an  early,  a  characteristic,  and  an  important  feature  of  the 
disease.  Lymphatics  involved  in  the  site  of  original  disease  readily 
convey  the  cancerous  material  to  neighboring  glands  and  these  may 
become  so  filled  with  the  infected  material  that  they  burst  their 
capsules.  It  is  a  curious  fact  that  dissemination  through  the 
lymphatics  varies  very  greatly  in  different  individuals  and  also 
in  different  situations  of  the  same  individual,  so  that  we  cannot 
with  any  certainty  predict  just  what  amount  of  dissemination  will 
take  place  in  any  given  case.  It  is  even  true  that  occasionally  the 
lymphatics  will  become  so  clogged  with  the  cancerous  material  that 
in  a  measure  they  disconnect  themselves  from  the  rest  of  the  system 
and,  for  a  time,  the  disease  seems  to  remain  localized.  But  this  we 
do  know,  that  the  proportion  of  instances  in  which  rapid  dissemina- 
tion will  certainly  occur  is  so  large  that  there  is  grave  danger  in 
the  delay  that  allows  such  a  progression  of  the  disease.  When 
secondary  infection  has  taken  place  through  dissemination,  the 
secondary  foci  usually  exhibit  a  remarkable  vitality  and  power  to 
exist  independently  and  to  in  time  become  the  starting  point  of 
other  foci. 

These  secondary  deposits  may  occur  -in  any  organ  or  in  fact  in 
any  tissue  of  the  body.  The  question  of  the  influence  of  heredity 
in  relation  to  carcinoma  is  most  unsettled;  there  is  so  much  to  be 


338  TUMORS  IN  CHILDREN 

said  upon  both  sides,  based  only  upon  theory,  that  we  may,  for 
practical  purposes,  await  more  definite  information. 

DIAGNOSIS. — The  diagnosis  is  rendered  somewhat  more  easy  by 
the  fact  that  carcinoma  is  somewhat  rare  in  children.  Yet  we  must 
not  be  unmindful  of  the  fact  that  it  may  occur  congenitally  as  well 
as  in  any  period  of  childhood  or  infancy.  Its  rarity  should  not 
make  us  unmindful  of  its  possible  existence.  One  of  its  most  con- 
stant features  in  children  is  its  very  rapid  growth.  This  rapidity 
of  growth  often  makes  it  simulate  an  inflammatory  swelling,  but 
in  the  latter  the  increase  of  size  is  more  rapid  and  with  this  there 
is  always  much  more  pain,  tenderness,  and  heat.  Redness  of  the 
surface  of  the  swelling  alone  is  of  no  value,  for  it  may  be  present 
in  inflammation  or  in  carcinoma,  so  but  little  importance  can  be 
attached  to  it,  except  as  it  is  associated  with  other  symptoms.  To 
this  there  might  be  one  exception  and  that  is  in  the  case  of  a  cold 
abscess,  which  would  not  have  the  characteristics  of  the  inflamma- 
tory swelling,  but  which  could  be  readily  diagnosed  by  exploratory 
puncture  and  aspiration. 

Gummata  might  for  a  time  offer  some  difficulty,  but  these  occur 
rather  late  in  childhood  and  there  would  be  the  other  signs  of  a 
well-developed  syphilis.  The  presence  or  absence  of  either  hard- 
ness of  the  part  or  of  fluctuation  would  be  of  doubtful  value  in 
differential  diagnosis  because  either  condition  may  be  present  in 
carcinoma  in  children. 

It  is  possible  to  mistake  carcinoma  of  the  skin  for  a  tuberculous 
lesion.  However,  cutaneous  carcinoma  is  almost  unknown  in 
childhood. 

Actinomycosis  has  features  which  are  characteristic  enough  to 
easily  distinguish  it. 

Sarcoma  exhibits  a  more  rapid  growth  than  carcinoma  and  has 
a  later  ulceration  (unless  the  skin  or  mucous  membrane  is  in- 
volved). Its  dissemination  is  along  the  blood  vessels  rather  than 
through  the  channel  of  the  lymphatics  and  the  constitutional  symp- 
toms are  always  of  later  appearance. 

To  state  it  more  definitely:  if  we  observe  a  tumor  with  well- 
defined  margins,  which  has  grown  without  much  early  pain  and  is 


VAEIETIES    OF    TUMORS  339 

not  very  tender  at  the  time  of  the  examination,  but  has  associated 
with  it  a  demonstrable  enlargement  of  the  adjacent  lymph  glands, 
while  unassociated  lymph  glands  remain  normal,  and  there  is  no 
ulceration  of  the  skin  or  any  well-defined  cause  for  the  lymph- 
adenitis, we  are  justified  in  considering  the  case  one  of  carcinoma. 
This  should  be  immediately  followed  by  an  examination  of  a  sec- 
tion of  the  growth,  so  that  the  clinical  diagnosis  may  be  backed  up 
by  the  laboratory. 

PROGNOSIS. — The  prognosis  is  always  unfavorable  in  children 
and  this  is  largely  influenced  by  the  fact  that  they  do  not  exhibit 
the  varieties  of  carcinoma  which  are  found  in  the  adult  to  be 
amenable  to  surgical  interference.  Instead  of  the  accessible 
epithelioma  or  the  slow-growing  scirrhus,  which  are  observed  com- 
monly in  the  adult,  in  children  the  disease  is  most  often  a  very 
rapidly  increasing  and  malignant  encephaloma. 

TREATMENT. — The  only  treatment  that  promises  anything  in 
the  way  of  relief  or  possible  cure  is  an  early  and  adequate  re- 
moval of  the  part  affected  with  all  of  its  associated  lymphatics  and 
lymph  nodes,  and  this  can  only  be  done  when  the  diagnosis  has 
been  made  at  a  very  early  stage  of  the  disease.  Therefore  we  may 
state,  as  a  general  proposition,  that  the  prognosis  and  the  treat- 
ment depend  almost  entirely  upon  the  accuracy  of  the  diagnosis  and 
upon  how  early  it  has  been  made.  And,  even  with  such  advantages, 
the  prognosis  is  still  very  grave  because  surgical  ingenuity  has 
covered  every  detail  of  the  work  and  with  our  present  knowledge 
of  the  disease  nothing  has  been  left  undone  to  offer  all  possible 
relief.  And  yet,  with  it  all,  we  are  face  to  face  with  the  fact  that 
the  disease,  by  its  insidious  growth,  its  early  painless  onset,  its 
characteristic  illimitation,  and  its  power  of  dissemination,  finally 
baffles  the  best  skill  of  the  best  surgeons. 

But  even  though  it  has  been  decided  that  the  case  is  one  that 
offers  no  hope,  and  although  it  come  under  the  heading  of  inoperable 
carcinoma,  there  is  much  that  can  be  done  to  afford  relief  to  the 
individual  affected.  Local  cleanliness  goes  a  great  ways  in  pre- 
venting unnecessary  suffering  and,  therefore,  very  frequent  dress- 
ings with  absorbent  powders  to  check  or  limit  the  discharges  and 


340  TUMORS  IX  CHILDREN 

reduce  the  fetor  are  indicated  in  every  case.  The  judicious  adminis- 
tration of  an  opiate  is  not  alone  helpful,  but  is  very  much  indicated. 
By  a  careful  and  painstaking  regulation  of  the  diet  and  activities 
of  the  child  as  well  as  its  hygienic  surroundings,  much  is  done  to 
rid  the  disease  of  many  of  its  most  horrible  features. 

The  use  of  the  X-ray  promised  well  for  a  time,  but  its  ultimate 
result  has  been  disappointing,  and,  after  thorough  testing  by  many 
observers,  its  use  has  become  limited  to  its  local  effect. 

The  toxin  and  serum  therapy  methods  of  treating  carcinoma 
are  still  unsatisfactory  and  uncertain  and  not  free  from  risk.  At 
the  present  time,  the  method  has  no  place  in  the  treatment  of 
carcinoma  in  children. 

Teratomata. — Teratomata  of  all  varieties  may  occur  in  infancy 
and  in  childhood.  There  are  two  forms:  the  external  and  the  in- 
ternal. Keen's  definition  is:  "a  teratoma  is  an  irregular  conglom- 
erate mass  containing  the  tissues  and  fragments  of  viscera  belong- 
ing to  a  suppressed  fetus  attached  to  an  otherwise  normal  indi- 
vidual." 

PATHOLOGY. — The  EXTERNAL,  FORM  is  almost  exclusively  limited 
to  the  skull  and  vertebral  column.  To  make  the  matter  more  clear 
it  may  be  necessary  to  refer  briefly  to  the  subject  of  conjoined 
twins.  Conjoined  twins,  of  course,  may  exhibit  many  different 
forms,  the  result  largely  of  circumstances,  because  in  their  produc- 
tion one  goes  on  to  more  or  less  complete  development,  while  the 
other  has  only  a  minor  portion  of  its  parts  developed.  This  latter 
is  called  the  parasitic  fetus,  while  the  stronger  and  developed  fetus 
is  called  the  autosite.  In  the  instances  in  which  the  development 
of  the  parasitic  fetus  is  so  poor  that  it  resembles  merely  a  tumor, 
which,  upon  dissection,  may  contain  a  few  vertebrae  or  almost  undis- 
tinguishable  fragments  of  viscera  or  skin,  it  is  called  a  teratoma. 
The  relation  between  parasitic  fetuses  and  teratomata  has  been 
established  and  its  discussion  is  unnecessary  here. 

The  INTERNAL  TERATOMATA  occur  in  like  manner  to  the  external 
and  have  the  similar  varieties  of  development  and  form.  They 
differ  from  the  external  in  that  they  are  inclosed  in  a  cyst  and  that 
they  are  dangerous  to  the  life  of  the  autosite  from  mechanical  inter- 


VARIETIES    OF    TUMORS  341 

fereiice  with  function  and  from  their  occasional  tendency  to  malig- 
nancy. In  this  particular  they  differ  materially  from  the  external 
variety,  which  merely  causes  inconvenience  by  its  presence  and 
attachments. 

TREATMENT. — The  treatment  of  teratomata  is  one  that  must 
be  decided  individually  for  each  case.  There  are  many  factors 
which  enter  into  a  consideration  of  operative  relief  and  not  the 
least  of  these  is  the  opposition  which  the  surgeon  may  meet  from 
the  relatives  of  the  afflicted  child,  who  may  see  a  possible  source  of 
gain  in  the  little  one's  affliction  being  exhibited.  In  the  external 
form  we  merely  have  the  question  of  inconvenience  to  the  child  to 
consider  plus  the  danger  of  any  operative  procedure.  In  the  internal 
form  there  is  real  danger  to  the  child,  which  obtains  as  long  as 
the  growth  is  left  undisturbed.  Serious  results  may  result  mechan- 
ically at  any  time  and  may  be  sufficient  to  destroy  life.  And,  again, 
the  operative  procedure  is  much  less  simple  and  much  more  fraught 
with  danger  than  in  the  external  form.  These  considerations  alone 
make  it  necessary  to  determine  the  course  to  pursue  in  any  given 
case  by  the  individual  factors  present  at  the  time. 

Angiomata. — Angiomata  are  tumors  which  consist  of  an  abnormal 
formation  of  blood  vessels.  These  tumors  occur  in  three  VARIETIES  : 
the  simple  nevus,  the  cavernous  nevus,  and  the  plexiform  angioma. 
This  latter  variety  is  most  apt  to  appear  about  the  temples  and, 
less  frequently,  on  the  arms,  legs,  or  fingers.  However,  it  may  occur 
in  any  situation  in  which  there  is  connective  tissue. 

The  commonest  form  of  all  is  the  simple  nevus,  which  usually 
appears  upon  the  skin  or  occasionally  upon  the  mucous  membranes 
as  a  patch  of  discoloration.  The  varying  color  between  blue  and 
pink  depends  upon  the  character  of  the  abnormal  vessels,  so  that 
when  the  venules  predominate  the  color  will  be  bluish,  and  if  the 
arterioles  are  abundant  then  the  color  will  be  pinkish.  Occasionally 
the  ordinary  nevus,  which  is  embedded  in  fat  and  surrounded  by 
a  network  of  lymphatics  will  exhibit  a  remarkable  richness  in 
these  lymphatics,  and,  as  these  predominate  over  venules  and 
arterioles,  it  is  called  a  lymphangioma. 

It  is  possible  for  the  simple  nevus  to  become  cavernous  or  even 


342 


TUMORS  IN  CHILDREN 


plexiform.  When  this  occurs  there  is  usually  not  alone  a  trans- 
formation of  type,  but  this  is  accompanied  by  an  extension  both  on 
the  surface  and  deeper  in.  A  cavernous  nevus  is  usually  situated 
upon  the  skin,  but  they  have  been  reported  as  occurring  in  many 
other  situations.  It  is  generally  of  rather  slow  growth  and  may, 
because  of  its  size  and  situation,  become  very  annoying. 

CHARACTERISTICS. — Nevi  differ  greatly  in  size.  Some  are  so 
small  as  to  be  almost  imperceptible,  while  others  may  extend  over 
the  whole  limb  or  act  mechanically  in  displacing  some  important 
organ.  They  may  be  multiple.  The  smaller  ones  tend  to  disap- 
pear. Irrespective  of  the 
type,  they  may  remain 
stationary  for  an  indefi- 
nite period,  or  may  be- 
come at  any  time  the 
site  of  an  acute  inflam- 
mation, with  all  of  the 
dangers  which  are  at- 
tendant upon  such  a  con- 
dition in  a  situation  rich 
in  blood  vessels  and  lym- 
phatics and  poor  in  the 
power  of  resistance.  All 
angiomata  are  congenital 
or  occur  during  the  first 
few  weeks  after  birth. 

PROGNOSIS. — Degenerative  processes  sometimes  occur  in  children, 
so  that,  after  some  slight  injury,  there  may  follow  necrosis  or  gan- 
grene. The  dangers  from  hemorrhage  have  been  much  exaggerated. 
The  prognosis  is  always  good  as  regards  life  and  health,  for  the 
growths  interfere  with  neither. 

The  TREATMENT  is  by  excision  when  the  area  affected  is  not 
too  large  for  such  a  procedure.  Caustics,  curetting,  and  electrolysis 
all  have  their  advocates,  but  for  clean,  satisfactory  work  in  children 
excision  is  by  far  the  best  method  whenever  practical  or  liquid  car- 
bon dioxid  may  be  serviceable. 


FIG.  114. — ANGIOMA.     (Beers). 


VARIETIES    OF    TUMORS  343 

Lymphangioma. — As  has  already  been  stated,  when  there  are  an 
abnormal  formation  of  the  lymphatics  and  a  preponderance  of  these 
over  the  blood  vessels  in  the  part  and  a  tumor  is  formed,  it  is  called 
lymphangioma.  Or,  in  other  words,  lymphangioma  bears  the  same 
relationship  to  the  lymphatics  as  angioma  does  to  the  blood  vessels. 
As  in  angiomata,  there  are  three  VARIETIES  :  the  lymphatic  nevus, 
the  cavernous  lymphangioma,  and  the  lymphatic  cyst. 

The  lymphatic  nevus  is  practically  colorless,  although  at  times 
it  may  be  of  a  slight  pinkish  hue,  or,  if  situated  upon  one  of  the 
mucous  surfaces,  it  may  be  slightly  yellowish. 

A  cavernous  lymphangioma  may  become  cystic  in  its  center,  but 
this  change  is  not  common.  The  most  typical  appearance  is  as  it 
occurs  in  the  neck  as  a  congenital  swelling,  appearing  as  a  trans- 
lucent cyst  filled  with  lymph.  One  of  their  peculiarities  is  their 
tendency  to  disappear  after  a  period  in  which  they  have  become 
quite  inflamed.  It  is  this  combination  of  inflammation  and  subse- 
quent disappearance  which  makes  them  so  rare  after  childhood. 
These  tumors  have  no  limiting  capsule  and  are  almost  invariably 
congenital.  Innocent  of  itself,  such  a  tumor  may  cause  considerable 
danger  because  of  its  mechanical  interference  with  perfect  function- 
ing of  an  organ  or  part.  The  tumor  may  remain  stationary  in- 
definitely or  increase  rapidly  in  size,  or  even  become  the  site  of 
infection.  It  is  liable  to  all  of  the  degenerative  changes  which 
occur  in  other  tumors.  There  is  no  limit  to  the  situation  in  which 
it  may  occur,  although  the  favorite  sites  are  the  neck,  the  shoulder, 
or  axilla  or  upper  part  of  the  arm,  and  the  tongue,  the  lips  and 
the  cheek. 

DIAGNOSIS. — The  diagnosis  is  made  easier  if  the  tumor  is 
present  at  birth,  but  this  is  not  always  the  case  and,  therefore,  some 
confusion  might  occur  if  this  fact  was  not  recalled.  The  appear- 
ance of  the  skin  immediately  over  the  tumor  is  normal  or  nearly  so 
(there  may  be  a  slight  paleness)  if  inflammation  is  absent.  The 
tumor  is  not  compressible  unless  the  number  of  blood  vessels  in  it 
is  large  and  if  the  latter  condition  obtained  then  the  color  would 
be  changed.  This  incompressibility  helps  to  distinguish  it  from  an 
angioma.  But  in  cases  of  doubt  the  aspirating  needle  may  be  used 


344  TUMORS  IN  CHILDREN 

and  if  clear  lymph  is  withdrawn  through  the  needle  the  tumor  is 
lymphangioma.  But,  on  the  other  hand,  if  there  is  a  perfect  ad- 
mixture of  blood  and  lymph,  then  it  is  an  angioma.  There  is  -c/he 
precaution,  however,  that  must  be  taken  into  account  in  aspiration: 
the  withdrawn  fluid  must  represent  the  content  of  the  tumor  and 
not  be  the  content  of  the  tumor  plus  blood  from  an  outside  source 
as  the  result  of  injury  by  the  needle. 

PROGNOSIS. — There  is  but  little  danger  from  a  lymphangioma 
unless  so  situated  that  by  its  mechanical  interference  it  causes  symp- 
toms. Any  rapid  growth  of  the  tumor  should  at  once  excite  the 
suspicion  of  implication  with  sarcoma.  This  should  be  determined 
immediately  by  the  microscope.  The  accidental  rupture  of  the 
tumor  often  results  in  a  most  troublesome  lymphorrhea,  which  is 
disastrous  to  the  child's  general  health. 

TREATMENT. — The  treatment  is  by  excision.  This  is  modified 
to  some  extent  by  the  situation  of  the  tumor.  In  the  planning  of 
the  operation  the  surgeon  must  recall  that  these  tumors  may  extend 
very  deeply  below  the  surface  and  involve  many  important  organs 
or  vessels.  The  absence  of  any  limiting  capsule  makes  the  matter 
of  the  dissection  of  the  tumor  one  of  great  nicety,  skill,  and  patience. 
It  is  very  annoying  to  the  surgeon  to  commence  an  operation  upon 
what  may  seem  by  examination  to  be  rather  a  superficial  lesion  and 
to  find  that  an  unusual  amount  of  skill  and  time  is  demanded  for 
the  removal  of  the  growth.  And  what  is  more  annoying  still  is  to 
find  that,  after  this  period  of  most  trying  work,  the  tumor  which  is 
finally  removed  appears  very  shrunken  and  insignificant,  indicating 
in  no  way  the  difficulty  of  its  removal.  If  the  tumor  is  so  situated 
that  it  is  impracticable  to  do  a  complete  excision,  partial  excision 
may  be  the  operation  of  selection.  After  partial  excision,  injections 
of  iodin,  phenol,  or  bichlorid  of  mercury  may  be  used  to  produce 
fibrosis  in  the  remaining  portions  and  favor  their  shrinkage.  In 
some  situations  it  is  possible  to  apply  pressure  and  this  method  in 
combination  with  injections  ought  to  produce  some  favorable 
results. 

In  every  instance  the  parents  of  the  child  should  be  made  ac- 
quainted with  the  fact  that  what  appears  as  a  vetfy  superficial  affair 


VARIETIES    OF    TUMORS  345 

may  be  in  reality  a  very  deep-seated  one  and  that  nothing  but  the 
operation  will  clearly  determine  the  fact. 

Tapping  has  never  been  markedly  successful,  except  in  excep- 
tional instances  of  a  single  cyst  with  thinned-out  walls. 

Cystomata. — Representative  of  cystomata  in  childhood  there  are 
the  cystic  growths  which  occur  in  connection  with  the  jaws.  In 
one  form  there  occurs  an  epithelial  infolding  upon  the  alveolar  mar- 
gin and  this  results  in  cystic  enlargement.  Such  growths  are  mul- 
tilocular. 

The  cysts  arising  from  the  tooth  follicles,  or  which  have  their 
genesis  in  misplaced  teeth,  are  called  dentary  cysts.  When  arising 
from  a  misplaced  tooth,  it  may  be  either  one  of  the  temporary  or 
the  permanent  sets.  Such  cysts  contain,  in  addition  to  the  misplaced 
tooth,  a  fluid  of  a  varying  character,  which  may  even  be  purulent. 

Any  enlargement  of  the  jaw  about  where  a  tooth  should  have 
appeared  should  at  once  arouse  the  suspicion  of  cystoma,  and  this 
becomes  practically  positive  when  we  arc  able  to  demonstrate  more 
or  less  distinct  crackling  of  the  jaw  at  that  point. 

The  diagnosis,  however,  can  be  definitely  cleared  up  by  free 
incision,  in  which  event  the  fluid  and  tooth  are  removed  if  it  be  a 
cystoma  of  that  type. 

Retention  Cysts. — It  would  be  unwise  to  leave  the  subject  of 
tumors  in  childhood  without  giving  some  consideration  to  a  form 
of  tumefaction  which  bears  no  direct  relationship  to  the  tumors 
which  we  have  already  considered,  but  which  must  be  taken  into 
account  when  we  consider  the  diagnosis  and  treatment.  We  refer 
to  retention  cysts. 

ETIOLOGY. — These  are  swellings  that  are  caused  by  some  ob- 
struction of  the  outlet  of  a  gland,  or  the  retention  of  its  excretions 
or  secretions  in  a  previously  existing  space  and  in  sufficient  amount 
to  cause  symptoms  or  become  palpable.  The  obstruction  itself  may 
be  occasioned  by  many  factors,  so  that,  irrespective  of  the  retention 
cyst  itself,  we  have  to  differentiate  and  place  in  their  proper  rela- 
tionships to  the  cyst  the  following: 

(a)  Pressure  from  tumors. 

(b)  Inflammation  and  its  consequent  swelling. 


346  TUMORS  IN  CHILDREN 

(c)  Cicatricial  constriction. 

(d)  Flexion  or  twisting  of  the  duct  of  the  gland. 

(e)  Valvular  insufficiency  or  closure. 

(f)  Mechanical  obstruction  within  the  lumen  of  the   duct,   as 
by  concretions,  parasites,  or  foreign  body. 

(g)  Alteration  in  the  excretion  or  secretion  of  the  gland. 

It  will  be  readily  observed  that  many  of  the  conditions  which 
would  result  in  retention  cysts  in  adults  are  absent  in  childhood  and, 
therefore,  the  occurrence  of  this  form  of  tumefaction  is  much  rarer 
in  children  than  in  adult  life. 

Congenital  cystic  kidney  is  not  uncommon  in  infancy.  In  fact, 
this  condition  is  frequently  the  cause  of  death  of  the  fetus.  Infants 
who  are  born  with  double  cystic  kidneys  usually  die  very  early 
from  uremia  and  it  is  almost  a  certainty  that  such  infants  cannot 
live  but  one,  two,  or  three  days.  Most  of  them  are  dead-born,  but 
if  they  survive  it  is  only  for  a  few  hours,  as  a  rule.  However,  if 
but  one  kidney  is  involved,  the  infant  may  live  indefinitely  and 
allow  of  an  operation  being  performed  later  if  the  size  and  situation 
of  the  cyst  do  not  prohibit  the  procedure.  If  easily  accessible  and 
of  small  size  and  its  mechanical  pressure  has  not  interfered  too 
seriously  with  the  functioning  of  other  organs,  the  procedure  gives 
the  infant  a  good  chance  for  life. 

A  nephritis  occurring  in  an  infant  from  any  cause  may  be  the 
direct  agent  in  bringing  about  an  obstruction  or  plugging  of  the 
uriniferous  tubules,  just  as  sometimes  happens  in  adults.  The  ob- 
struction may  be  from  a  hyperplasia  of  the  connective  tissues  of  the 
part  or  may  be  due  to  clots  or  foreign  material.  The  tubules  then 
dilate  and  form"  cysts. 

In  other  instances  there  may  occur  a  developmental  failure  of 
perfect  continuity  between  the  renal  and  the  collecting  tubules  and 
this  may  be  the  obstructing  cause.  Or  one  or  both  kidneys  may  be 
small  at  birth  and  composed  largely  of  connective  tissue  and  mul- 
tiple small  cysts. . 

DIAGNOSIS. — Before  taking  up  separately  the  treatment  and 
prognosis  of  hydronephrosis  and  ranula,  we  wish  to  speak  of  reten- 
tion cysts  in  general.  In  the  diagnosis  we  must  always  recall  that 


347 

the  cyst  is .  always  located  at  or  near  an  excreting  or  a  secreting 
organ  or  has  some  connection,  either  direct  or  indirect,  with  the 
duct  of  such  an  organ.  Thus  we  expect  some  interference  with 
excretion  or  secretion  from  the  affected  gland.  Pain  would  depend 
largely  upon  the  size  of  the  obstructing  cause  and  the  situation  of 
the  affected  part  and  also  whether  or  not  inflammation  was  present. 
Inflammation  is  so  commonly  the  cause  of  the  obstruction,  however, 
that  pain  is  usually  an  early  and  more  or  less  prominent  feature. 
Exploratory  puncture  should  always  be  done  if  the  situation  of  the 
tumor  warrants  its  performance.  Only  in  this  way  can  we  be  positive 
of  its  nature. 

PROGNOSIS. — The  prognosis  depends  very  largely  upon  the  im- 
portance of  the  gland  affected  and  whether  it  is  located  superficially 
or  deep.  Of  course  infection  adds  another  element  with  which  we 
have  to  deal. 

TREATMENT. — The  treatment  is  purely  surgical  and  if  the  ob- 
structing cause  is  one  that  can  be  removed  it  must  be  done.  If 
the  cause  cannot  be  removed  then  the  indications  are  to  withdraw 
the  fluid  in  the  cyst  and  establish  drainage.  It  may  occur  that 
the  obstructing  cause  is  one  which  totally  destroys  the  outlet  and 
in  such  instances,  the  cyst  should  be  removed  if  possible.  But  if 
adhesions  are  so  abundant  that  this  procedure  is  inadvisable  because 
of  possible  injury  to  adjacent  parts  or  because  of  the  length  of 
time  required  for  the  operation,  then  exposure  of  the  cyst  walls  and 
cauterization  and  packing  with  gauze  may  be  done  to  establish 
granulation  and  final  closure. 

HYDRONEPHROSIS. — Hydronephrosis  occurs  as  a  dilatation  of 
the  pelvis  of  the  kidney  with  subsequent  atrophy  of  the  organic 
parenchyma.  This  condition  may  occur  congenitally  or  be  acquired 
and  may  be  either  unilateral  or  bilateral.  The  congenital  cases  are 
the  commoner  ones.  It  is  not  necessary  in  its  production  that  the 
retention  of  urine  be  complete,  for  the  amount  and  degree  of  reten- 
tion depend  largely  upon  the  obstructing  cause.  The  symptoms, 
other  than  the  demonstration  of  the  tumor,  are  very  variable  or 
may  be  entirely  absent.  The  diagnosis  is  most  often  made  from 
the  presence  of  an  abdominal  tumor.  This  tumor  is  spherical, 


348  TUMORS  IX  CHILDREN 

smooth,    and   fluctuating   and    very   intimately   connected    with   the 
kidney. 

In  the  instances  in  which  the  tumor  is  unilateral  the  diagnosis 
is  rendered  somewhat  easy,  for  there  are  the  unilateral  bulging  and 
flatness  upon  percussion  and  the  connection  with  the  kidney  can 
be  readily  mapped  out.  But,  when  occurring  bilaterally,  the  diag- 
nosis is  much  complicated.  Exploratory  puncture  yields  a  trans- 
parent fluid  which  contains  urea  or  uric  acid.  Echinococcus  of  the 
kidney,  while  very  rare  in  children,  may  closely  simulate  hydro- 
nephrosis.  Aspiration  of  the  tumor  in  echinococcus  would  yield  a 
fluid  which  would  show  the  absence  of  the  ordinary  urinary  con- 
stituents and  the  presence  of  the  "booklets"  which  are  peculiar  to 
echinococcus.  Very  large  ovarian  tumors  are  niore  likely  to  be 
mistaken  for  hydronephrosis,  although  they  are  rare.  Such  tumors 
are  spherical,  smooth,  and  fluctuating,  but  they  arise  in  the  false 
pelvis  and  occupy  the  region  of  the  umbilicus  and  the  hypogastrium, 
while  the  lateral  portions  of  the  back  are  free  from  the  presence 
of  the  tumor.  The  position  of  the  tumor  and  the  absence  of  demon- 
strable connection  with  the  kidney  serve  to  distinguish  it  even  with- 
out exploratory  punctures. 

Dermoids.  — These  are  tumors  which  are  furnished  with  skin,  but 
which  grow  in  situations  in  which  skin  is  not  found  under  normal 
conditions. 

The  simplest  condition  of  a  dermoid  is  a  more  or  less  globular 
sac  or  cyst,  the  inner  wall  of  which  is  lined  with  striated  epithelium 
furnished  with  hair,  sebaceous  glands,  and  sweat  glands,  the  shed 
hair,  epithelium,  and  glandular  excretions  forming  a  mass  within 
the  sac  and  distending  it. 

Sequestration  dermoids  are  those  which  occur  strictly  in  the 
regions  of  embryonic  fissures;  thus  they  are  common  about  the 
face  and  upon  the  trunk,  below  the  occipital  protuberance,  and 
along  the  center  of  the  back  to  the  coccyx  and  upward  after 
passing  through  the  perineum  through  the  center  of  the  abdomen, 
thorax,  and  neck.  In  the  scalp  the  commonest  situation  is  over  the 
anterior  fontanelle,  but  with  the  occipital  protuberance  as  a  close 
second. 


VARIETIES   OF   TUMORS  341) 

The  rarer  form  of  dermoid  is  the  tubulodermoid,  which  arises 
in  what  are  known  as  obsolete  canals. 

Dermoids  usually  remain  quiescent,  or  at  least  this  is  true  of 
them  as  a  class,  until  the  time  of  puberty,  when  they  may  take  on 
decided  changes.  As  they  are  so  commonly  pedunculated,  their  ex- 
tirpation is  generally  an  easy  procedure. 

Keloid. — Keloids  may  arise  spontaneously,  but  their  usual  appear- 
ance is  after  an  injury.     However,  there  is  always  some  doubt   as 
to  the  spontaneous  origin  because  even  with  great  care  we  cannot 
always  be  certain  that  some  slight  injury  has  not  existed  but  been1 
overlooked.     Keloids  are  connective  tissue  growths  in  the  corium. 

Their  ETIOLOGY  is  unknown,  although  there  is  much  to  suggest 
a  microbic  genesis  when  clinically  we  observe  that  their  common 
association  is  with  suppurative  processes. 

CHARACTER. — They  may  appear  at  any  time  during  life 
but  are  most  common  after  the  period  of  childhood.  When  they 
occur  they  are  usually  single.  The  keloid  is  sharply  defined,  raised 
above  the  surface  of  the  skin,  freely  movable,  and  of  variable  shapes. 
Not  uncommonly  there  are  projections  which  run  into  neighboring 
parts  and  these  have  frequently  been  likened  to  claws.  In  rare 
instances  the  growth  may  be  pedunculated.  The  surface  is  usually 
smooth  and  white,  but  may  have  a  pinkish  hue  if  it  is  very  vascular. 
Occasionally  we  find  instances  in  which  the  number  of  such  growths 
may  reach  a  hundred  or  more,  but  in  these  cases  it  is  generally  pos- 
sible to  trace  a  decided  hereditary  influence  or  a  constitutional 
taint. 

SYMPTOMS. — At  times  there  may  be  some  tenderness  about  the 
growth,  or  pain  may  actually  exist,  but  these  symptoms  are  uncom- 
mon. Outside  of  these,  and  a  possible  itching  or  burning  sensation, 
the  only  subjective  symptoms  are  those  which  are  due  to  the  in- 
convenience caused  by  the  situation  of  the  growth. 

PROGNOSIS. — Growth  is  slow  but  persistent  and  resists  all  forms 
of  treatment,  although  there  are  cases  in  which  spontaneous  im- 
provement occurs.  The  fact  that  the  growth  may  follow  any  slight 
injury  (as,  for  example,  vaccination,  ear-piercing,  burns,  etc.)  and 
is  not  influenced  by  any  treatment,  and  is  apt  to  recur  after  removal, 


350  TUMORS  IN  CHILDREN 

renders  the  prognosis  rather  uncertain  and  unfavorable.  But,  upon 
the  other  hand,  it  is  very  unusual  for  keloids  to  ulcerate  or  acquire 
malignancy. 

The  TREATMENT  remains  uncertain  because  of  the  tendency  to 
recurrence.  The  only  method  which  at  present  seems  to  offer  a 
reasonable  chance  of  relief  is  the  application  of  the  X-ray  or  a  com- 
bination of  excision  immediately  followed  by  the  X-ray  treatments 
or  radium.  Some  operators  have  experienced  success  with  excision 
coupled  with  a  very  wide  margin  of  incision  about  the  growth,  so  as 
to  include  all  of  the  affected  vessels.  Still  others  advise  mutilation 
by  numerous  linear  incisions  dividing  the  vessels. 

With  such  uncertainty  existing,  it  is  advisable  to  let  the  growth 
alone  unless  there  occur  sufficient  grounds  of  surgical  interference 
on  account  of  the  subjective  symptoms. 


PART  II 
REGIONAL  SURGERY 


5fJ 

H  ff  H  J  J 

;.     •:.     P.  [/  L   \  r\  I  P  vr-TG- 


SECTION  X 

THE  HEAD  AND  NECK 
CHAPTEK  XLIV 

AFFECTIONS    OF    THE    HEAD 
f 

CONGENITAL  AFFECTIONS 

ENCEPHALOCELE 

Encephalocele  is  a  congenital  tumor  composed  of  a  sac  contain- 
ing fluid  or  nervous  elements  in  its  interior,  and  held  by  a  pedicle 
of  dura  mater  which  traverses  a  bony  defect  in  the  skull. 

Varieties. — We  distinguish  three  varieties  according  to  the  con- 
tents of  the  sac: 

(a)  Meningoceie — the  tumor  is  composed  of  a  sac  containing 
only  fluid,  like  cerebrospinal  fluid. 

(b)  Encephalocele — the  tumor  is  composed  of  a  sac  containing 
nervous  elements   (but  no  structure  peculiar  to  any  portion  of  the 
brain). 

(c)  Hydrencephalocele — the  tumor  is  composed  of  a  sac  con- 
taining nervous  elements  and  fluid. 

Situation. — There  are  two  points  of  election  for  the  site  of  these 
tumors : 

(a)  The  occipital  region  in  the  median  line  above  the  external 
protuberance     where     hydrencephaloceles     and     meningoceles     are 
usually  found. 

(b)  The  frontal  region,  at  the  glabella,  the  usual  situation  of 
encephaloceles.     (Fig.  115.) 

Tumors  situated  in  the  occipital  region  are  usually  more  volu- 
minous, usually  pedunculated,  and  may  attain  a  great  size  owing  to 

353 


354 


AFFECTIONS  OF  THE  HEAD 


FIG.  115. — ANTERIOR  MENINGOCELE  SPRINGING 
FROM  ROOT  OF  NOSE.  (Kirmisson.) 


their  ever-increasing  fluid 
contents.  Thus  the  con- 
stantly distended  sac  and 
friction  of  the  everlying 
skin  subject  them  to  ulcera- 
tion,  rupture,  and  conse- 
q  u  e  n  t  fatal  meningitis. 
Those  in  the  frontal  region 
are  usually  small,  remain 
stationary,  and  are  not  a 
menace  to  life.  It  is  well  to 
remember  that  these  tumors 
when  large  may  form  an  ob- 
stacle to  normal  labor,  and 
present  obvious  difficulties 
of  antepartum  diagnosis. 

Pathology.  — T  h  e  s  e  tu- 
mors are  due  to  arrest  of  development,  and  it  is  not  unusual  to  find 
in  the  same  subject  the  coincidence  of  spina  bifida  and  cleft  palate. 
They  are  really  "cranial 
spina  bifida." 

It  must  be  remem- 
bered that  these  tumors 
are  in  no  sense  a  hernia 
cerebri,  first :  because  the 
sac  does  not  correspond 
to  the  membranes  of  the 
brain;  and  secondly:  the 
contents  of  the  sac,  or 
nervous  elements,  are 
typical  of  no  part  of  the 
brain. 

Symptoms.  — T  he  tu- 
mor is  of  varying  size 
and  consistency,  accord- 
ing to  its  contents;  usu- 


FlG. 


116. — LARGE     OCCIPITAL      ENCEPHALOCELE. 
(After  Spitzy.) 


CONGENITAL  AFFECTIONS  355 

ally  pedunculated  when  situated  posteriorly.  The  overlying  skin 
is  thin,  devoid  of  hair,  and  often  the  site  of  angiomatous  patches. 
On  palpation  there  is  a  sense  of  fluctuation,  and,  while  in  some 
cases  the  tumor  may  be  reduced  by  pressure,  it  must  be  remembered 
that  convulsions  and  coma  may  thereby  be  the  result  of  cerebral 
compression. 

These  tumors  become  tense  when  the  child  cries  or  makes  an 
unusual  effort,  and  sometimes  expansile  movements  can  be  felt 
synchronous  with  the  heart  beat. 

Diagnosis. — These  tumors  may  be  confounded  with  cephalhema- 
tomata,  dermoid  cysts,  and  angiomata.  Keep  in  mind  the  char- 
acteristic features  of  these  tumors  as  to  location,  fluctuation,  reduci- 
bility,  and  the  discomfort  occasioned  by  pressure. 

Note  that  cephalhematomata  are  situated  laterally,  usually  on 
the  right,  are  not  reducible,  pressure  gives  rise  to  no  cerebral  dis- 
turbance, and  their  margin  is  formed  by  a  periosteal  ridge. 

Dermoid  cysts  are  found  near  the  anterior  fontanelle,  are  not 
reducible,  and  have  a  doughy  consistency. 

Angiomata  will  rarely  be  mistaken  since  they  are  not  well  de- 
fined or  of  significant  volume.  Though  rare,  it  is  well  to  remem- 
ber that  a  meningocele  has  been  mistaken  for  a  nasal  polypus. 
Owen  reports  a  case  of  meningocele  that  presented  through  the 
suture  between  the  orbital  plate  of  the  frontal  bone  and  the  cribri- 
form plate  of  the  ethmoid,  "where  its  appearance  so  closely  re- 
sembled that  of  a  nasal  polypus  that  its  removal  was  attempted 
with  a  pair  of  forceps — a  proceeding  which  entailed  a  fatal  attack 
of  meningitis." 

Treatment. — The  success  obtained  by  extirpation  is  well  estab- 
lished and  it  is  the  method  of  choice.  Neither  puncture  nor  injection 
is  satisfactory  nor  safe.  The  operation  is  indicated  except  where 
there  is  a  coincident  hydrocephalus  or  extreme  debility  of  the 
patient. 

OPERATION  consists  in  making  skin  flaps  to  cover  in  the 
wound  of  excision;  freeing  the  sac  to  its  pedicle;  ligation  of  the 
pedicle  without  opening  the  sac,  and  excision  of  the  mass.  The 
opening  in  the  bone  may  be  closed  by  an  osteoplastic  flap  chiseled 


356 


AFFECTIONS  OF  THE  HEAD 


from  the  adjacent  bone  and  the  wound  accurately  approximated  by 
several  layers  of  sutures.  The  dangers  of  this  operation  are:  first, 
the  operative  shock;  second,  leakage  of  the  eerebrospinal  fluid. 


MICROCEPHALUS 


Microcephalus  is  a  condition  in  which  the  cranium  is  abnormally 
small,  due  to  an  arrest  of  development  of  the  brain.  It  is  often 
associated  with  other  deformities,  such  as  encephalocele,  malforma- 
tions of  the  extremities,  and  arrested  development  of  the  genitals. 


FIG.  117. — MICROCEPHALUS  WITH  ENCEPHALOCELE.  (Dr.  Zacharie's  case.) 

\ 
(Fig.  117.)     These  children  are  feeble-minded,  the  intelligence  being 

diminished  in  variable  degrees;  their  physiognomy  is  that  of  the 
idiot. 

Treatment. — Lannelongue  has  proposed  to  relieve  this  condition 
by  excising  strips  of  bone  on  each  side  of  the  vertex  of  the  skull 
(craniectomy)  for  the  purpose  of  permitting  the  brain  to  expand. 
The  results,  however,  do  not  justify  this  procedure,  nor  is  it  founded 
on  scientific  facts,  since  the  undeveloped  brain  is  the  cause  and  not 
the  result  of  the  microcephalic  skull. 

The  treatment  of  this  condition  is  not  surgical  but  pedagogic. 
These  children  should  be  placed  in  special  institutions,  where  their 
physical,  mental,  and  moral  education  can  be  properly  supervised. 


CONGENITAL  AFFECTIONS 


,357 


CONGENITAL,    HYDROCEPHALUS 

Congenital  hydrocephalus  is  an  accumulation  of  cerebrospinal 
fluid  in  the  ventricles  of  the  brain.  As  Gushing  observes :  "Hydro- 
cephalus is  a  symptom  of  a  disease,  not  a  disease  itself."  Hence 
the  abnormal  accumulation  of  fluid  in  the  ventricles  indicates  the 
presence  of  a  diseased  secretory  function  (hypersecretion)  or  a 
mechanical  obstruction  preventing  the  fluid's  escape.  It  may  be 
that  congenital  syphilis  plays  an  important  role  in  causing  an  ab- 
normal increase  in  the 
amount  of  fluid  secreted, 
or  there  may  be  some  ob- 
struction which  prevents 
its  exit  through  the  fora- 
m  e  n  o  f  Magendie,  o  r 
a  degeneration  of  the 
arachnoid  which  blocks 
its  outlet  from  the  sub- 
arachnoid  space. 

Pathology.  — Whatever 
the  cause  the  results  pre- 
sent a  striking  clinical 
picture.  The  accumulat- 
ing fluid  gradually  dis- 
tends the  ventricles  and 
thins  out  the  surround- 
ing cerebral  tissue  until 
the  brain  forms  only  a 
thin  covering  for  the  enlarged  ventricles.  To  make  room  for  its 
increasing  contents  the  cranial  vault  is  correspondingly  extended. 
The  cranial  bones  are  thinned  and  atrophied,  the  fontanelles  are 
widened  and  tense,  the  sutures  distended,  and  the  head  attains 
enormous  proportion's.  The  disproportion  between  the  large  head 
and  the  small  triangular  face  is  weird.  (Fig.  118.)  These  chil- 
dren are  feeble  and  badly  nourished,  locomotion  is  retarded,  the 
intelligence  is  altered  in  varying  proportions ;  some  hydrocephalics 


FIG.  118. — HYDROCEPHALIC  CHILD.  (After  Willard.) 


358  AFFECTIONS  OF  THE  HEAD 

are  idiots  or  imbeciles,  others  are  simply  backward.  These  patients 
rarely  live  to  adult  life. 

Treatment. — The  treatment  up  to  the  present  time  is  entirely  ex- 
perimental and  the  results  disappointing.  In  the  presence,  however, 
of  what  seems  a  hopeless  problem,  experimental  surgery  should  not 
be  discouraged,  since  the  end  justifies  the  means.  To  eliminate  the 
syphilitic  element  every  case  should  receive  antisyphilitic  treat- 
ment (mercury,  "606"  injection,  etc.). 

The  SURGICAL  solution  of  the  hydrocephalic  problem  contem- 
plates the  evacuation  of  the  fluid:  (a)  by  intermittent  evacuation; 
(b)  by  permanent  evacuation. 

(a)  Intermittent  evacuation  may  be  done  by  tapping  the  ven- 
tricle with  a  fine  aspirating  needle  through  the  fontanelle  a  little 
external  to  the  median  line  to  avoid  the  superior  longitudinal  sinus ; 
or  the  fluid  may  be  evacuated  through  a  lumbar  puncture.     Simple 
puncture,  however,  has  given  disappointing  results,   since  there  is 
a    rapid    reaccumulation    of   fluid    within    a    few   hours    after    its 
withdrawal.      In    spite    of   the    discouraging   results,    v.    Bokay    is 
enthusiastic     in     advising     frequent    Tepeated     lumbar     puncture, 
and   reports   nine   cases   in  which   surprisingly   good   results   were 
obtained. 

The  author  regards  a  chronic  or  congenital  hydrocephalus  as 
cured  only  when  the  functional  disturbance  has  wholly  disappeared 
and  the  circumference  of  the  head  approaches  that  of  the  normal 
child.  The  age  of  the  nine  cases  at  the  beginning  of  his  treatment 
varied  between  three  and  nine  months.  The  treatment  lasted  from 
four  months  to  four  and  one-half  years.  Puncture  was  undertaken 
every  four  to  eight  weeks.  The  amount  of  cerebrospinal  fluid 
removed  at  each  seance  varied  between  20  and  40  c.  c.  The  num- 
ber of  punctures  were  from  9  to  32  (average  of  17).  Five  cases 
were  completely  cured.  Three  cases  showed  marked  improvement, 
and  one  case  no  result  whatever.  No  untoward  results  were  noted 
in  these  systematic  lumbar  punctures  carried  on  for  a  long  period. 
The  results  are  better  the  sooner  the  treatment  is  begun. 

(b)  Permanent   evacuation   contemplates   the    establishment    of 
continued  drainage  to  relieve  the  accumulating  fluid.     The  measures 


CONGENITAL  AFFECTIONS  359 

proposed  are  numerous  and  ingenious.     Among  these  may  be  men- 
tioned : 

(1)  Subcutaneous   drainage   between  the   arachnoid   spaces    and 
the  subaponeurotic  layer  of  the  scalp. 

(2)  Uniting  the  lateral  ventricle  with  the  longitudinal  sinus  by 
transplanting  a  portion  of  the  saphenous  vein. 

(3)  Cushing's   method   of   retroperitoneal    drainage    by   a    com- 
bined  laparotomy   and  laminectomy.      It   is   evident   that    all   these 
procedures  are  complicated,  that  they  necessarily  give  a  high  mor- 
tality and  as  yet  belong  to  the  domain  of  experimental  surgery. 

CEPHALHEMATOMA 

Cephalhematoma  is  an  effusion  of  blood  between  the  bone  of 
the  cranium  and  its  pericranium.  It  occurs  in  the  new-born,  is 
usually  limited  to  one  of  the  parietal  bones,  and  is  the  result  of 
traumatism  during  delivery. 

Pathology. — The  vessels  beneath  the  pericranium  are  torn  and 
blood  is  slowly  effused,  lifting  the  pericranium  from  the  bone,  and 
forming  a  tumor  which  is  localized  on  the  parietal  bone.  It  will 
be  recalled  that  the  pericranium  dips  down  between  the  sutures 
forming  the  intersutural  membrane,  thus  the  effusion  is  confined 
to  one  bone,  and  the  resulting  tumor  is  conformed  to  the  outline 
of  the  bone.  As  a  rule  the  cephalhematoma  appears  a  day  or  two 
after  birth. 

The  tumor  is  soft,  increases  in  size  for  several  days,  and  finally 
develops  a  bony  ridge  along  the  edge  of  the  bone,  which  throws  into 
sharp  contrast  the  soft  fluctuating  center,  and  thus  simulates  a  frac- 
ture of  the  skull.  The  tumor  subsides  very  slowly,  leaving  behind 
the  bony  rim  which,  after  a  time,  likewise  disappears.  The  only 
complication  is  their  possible  transformation  into  a  phlegmon. 

Diagnosis. — The  diagnosis  ought  not  to  be  difficult,  and  it  should 
not  be  mistaken  for  a  congenital  tumor  (encephalocele)  if  its  well- 
marked  characteristics  are  kept  in  mind:  (a)  its  lateral  situation; 
(b)  absence  of  pulsation  or  reducibility ;  (c)  its  soft  center  and  sur- 
rounding bony  rim. 


360  AFFECTIOXS  OF  THE  HEAD 

Treatment. — The  treatment  is  that  of  all  hematomata,  viz.,  pro- 
tection of  the  skin  from  infection  while  the  effusion  is  being  al>- 
sorbed.  There  are  no  topical  remedies  which  hasten  absorption. 
The  skin  over  the  lesion  may  be  protected  by  an  antiseptic  compress 
held  in  place  by  a  cap.  If  suppuration  occurs,  incision  and  drain- 
age as  in  abscess. 

FRACTURES    OF    THE    SKULL 

Fractures  of  the  skull  in  young  children  have  a  symptomatology 
and  prognosis  the  peculiarities  of  which  merit  special  attention. 

Injuries  to'  the  skull  are  caused  by  accidents  which  play  an 
important  role  in  the  life  of  the  child,  such  as  falling  down  stairs, 
roller  skating,  the  sports  and  games  of  childhood,  all  offer  endless 
possibilities  for  injury. 

Recall  the  fact  that  anatomically  the  skull  of  the  child  differs 
from  that  of  the  adult  in  the  fact  that  it  is  more  elastic,  ossification 
is  incomplete.  Treves  has  compared  the  skull  of  an  infant  to  that 
of  an  old  man  as  a  cranium  of  tin  would  be  to  a  cranium  of 
earthenware.  A  blow  that  would  dent  the  one  would  crack  the 
other.  As  long  as  the  fontanelles  are  open  the  soft  bones  of  the 
skull  are  protected  from  injury  by  their  great  elasticity.  Hence, 
(a)  fractures  of  the  skull  in  young  children  are  relatively  less 
serious  than  in  adults,  (b)  They  are  less  extensive  than  in  adults, 
as  they  do  not  have  the  same  tendency  to  extend  downward  and 
involve  the  base,  (c)  The  prognosis  is  better  in  children  than  in 
adults.  Mortality  from  fracture  of  the  skull  in  children  is  low: 
hence,  (d)  the  attitude  of  the  surgeon  toward  fractures  of  the  skull 
in  young  children  should  be  one  of  conservatism,  and  no  operative 
interference  should  be  contemplated  unless  the  indications  are  pro- 
nounced. If  in  doubt  do  not  operate. 

Although  injuries  to  the  head  of  the  child  are  relatively  not  of 
serious  consequence,  it  must  be  remembered  that  such  injuries  may 
be  followed  by  traumatic  meningocele,  meningitis,  and  at  a  later 
period  epilepsy.  The  secondary  results  of  a  blow  on  the  head  of 
a  child  are  always  indefinite. 


DERMOID  CYSTS  OF  THE  HEAD  3G1 

In  older  children  fractures  of  the  skull  are  accompanied  by 
typical  concussion ;  in  basal  fractures  by  bleeding  from  the  ear,  nose, 
and  mouth,  and  they  do  not  differ  from  similar  injuries  in  adults  in 
their  development  or  symptomatology. 

Treatment. — Although  the  prognosis  is  usually  benign,  these 
injuries  demand  vigilant  attention  and  careful  study.  Avoid  opera- 
tion if  there  is  no  cerebral  compression,  and  beware  of  converting 
a  subcutaneous  fracture  into  an  open  one.  The  dangers  of  infec- 
tion are  grave.  When  no  operative  interference  is  called  for,  the 
treatment  should  be  directed  toward  allaying  all  irritation  and  the 
restoration  of  the  injured  brain  structures  to  the  normal.  This 
may  be  accomplished  by  rest  in  bed,  an  ice-bag  to  the  head,  light 
diet,  and  the  administration  of  calomel. 

Illoway  believes  that  calomel  has  an  antiphlogistic  action  on 
the  brain  and  its  coverings,  and  is  effective  in  allaying  cortical 
irritation. 

When  there  are  present  cerebral  symptoms  of  intracranial 
hemorrhage  and  compression,  the  usual  operations  of  decompression, 
trephining,  and  removal  of  depressed  fragments  of  bone  are  indi- 
cated as  in  the  adult. 


DERMOID    CYSTS    OF    THE    HEAD 

These  cysts  are  due  to  an  ectodermal  inclusion  during  the  pro- 
cess of  closure  of  the  embryonal  clefts.  They  are  lined  by  true 
epithelium  presenting  all  the  characteristics  of  true  skin;  hence 
the  varied  contents  of  these  cysts:  Sebaceous  material,  hairs,  some- 
times teeth,  and  more  rarely  cartilage  or  bone.  Dermoid  cysts  of 
the  head  are  found  in  three  typical  situations — the  root  of  the  nose, 
the  anterior  fontanelle,  and  the  external  occipital  protuberance. 

Characteristics. — (a)  These  cysts  often  lie  quiescent  until  puberty 
before  they  disclose  their  presence,  (b)  They  have  no  connection 
with  the  overlying  skin,  (c)  They  are  deep  seated,  often  lie  in 
saucer-shaped  depressions  of  bone  by  a  pedicle,  (d)  They  have  a 
doughy  consistency,  (e)  They  are  not  reducible. 


362 


AFFECTIONS  OF  THE  EAK 


Diagnosis. — The  diagnosis  of  these  tumors  is  rarely  difficult  when 
their  location,  consistency,  and  noii-reducibility  are  kept  in  mind. 
(See  Meningocele,  p.  355.) 

Treatment. — Complete  extirpation.  There  is  no  class  of  tumors 
that  demand  more  careful  dissection  of  the  cyst  wall  intact,  in- 
cluding the  pedicle  down  to  the  bone.  If  the  smallest  portion  is 
left  the  tumor  may  be  reproduced  or  an  intractable  fistula  may  be 
established. 

In  cysts  of  the  anterior  fontanelle  the  cyst  wall  may  be  adherent 
to  the  dura  and  require  the  most  careful  dissection  in  separating 
the  two  structures. 

Cysts  of  the  external  occipital  protuberance  may  be  actually 
situated  within  the  cranial  cavity  and  may  require  opening  of  the 
cerebellar  fossa  for  their  successful  removal. 


CHAPTER  XLV 

AFFECTIONS    OF   THE    EAR 

MALFORMATIONS  OF  THE  EXTERNAL  EAR 

Various  deformities  of  the  ear  are  observed  either  as  the  result 

of  accident  or,  as  is  most  frequent  in 
children,  due  to  congenital  malforma- 
tion. 

Among  these  deformities  we  note 
complete  or  partial  absence  of  the 
auricle ;  bifid  lobule ;  "bat-ears"  ;  su- 
pernumerary auricles;  displaced  au- 
ricle ;  atresia  of  the  auditory  canal. 

It  is  obvious  that  many  of  these 
defects  can  be  corrected  by  surgical 
intervention.  Supernumerary  auri- 
cles may  be  excised.  "Bat-ears"  (Fig. 
119),  when  particularly  unsightly, 
mav  be  drawn  in  toward  the  head 


FIG.  119. — "BAT-EARS." 


FOREIGN  BODIES  IN  THE  EAR  303 

by  dissecting  off  a  flap  of  skin  at  the  junction  of  the  auricle  with 
the  mastoid  and  suturing  the  raw^  surfaces  together.  Bifid  lobule  is 
easily  corrected  by  freshening  the  edges  of  the  defect  and  applying 
sutures.  Atresia  of  the  canal,  when  membranous,  is  easily  cor- 
rected; but  when  the  obstruction  is  osseous  it  may  or  may  not  be 
possible  to  remedy  the  defect. 


FOREIGN   BODIES   IN   THE    EAR 

In  very  young  children  where  instinct  dominates  there  is  a 
natural  fondness  for  introducing  foreign  bodies  into  the  natural 
passages.  Hence,  the  extraction  of  foreign  bodies  from  the  ear, 
nose,  esophagus,  and  trachea  constitutes  an  important  chapter  in 
the  surgery  of  children.  A  great  variety  of  small  objects  may  be 
introduced  into  the  ear,  such  as  buttons,  beads,  pins,  etc.  Again, 
insects,  flies,  bugs  may  crawl  into  the  meatus  and  become  caught 
in  the  cerumen.  It  is  evident  that  the  presence  of  these  foreign 
bodies  may  be  the  cause  of  intense  pain,  swelling,  inflammation, 
suppuration;  and  even  fatal  results  are  possible  from  perforation 
of  the  membrana  tympani,  infection  of  the  inner  ear,  and  subse- 
quent meningitis. 

In  all  cases  of  earache  examine  the  auditory  canal  with  an  ear 
speculum,  a  good  light,  and  head  mirror.  If  the  patient  is  very 
young  and  intractable  employ  light  ether  anesthesia.  In  compli- 
cated cases  or  cases  of  long  standing  secure  if  possible  the  services 
of  an  otologist. 

Treatment. — First  fill  the  canal  with  glycerin  or  oil  to  destroy 
insects  and  lubricate  the  passageway;  then  use  warm  water,  syring- 
ing the  ear  with  moderate  force.  Foreign  bodies  recently  intro- 
duced will  be  dislodged  by  this  method.  If  not  successful  employ 
light  anesthesia  and  extract  by  means  of  a  pin  bent  like  a  fish-hook 
or  a  very  fine  forceps.  All  instruments  should  be  cautiously  intro- 
duced in  order  not  to  wound  the  drum  or  canal.  In  extreme  cases 
it  will  be  necessary  to  make  an  incision  behind  the  ear — in  the  retro- 
auricular  groove — and  open  the  cartilaginous  part  of  the  meatus  in 
order  to  expose  the  inner  part  of  the  canal. 


364  FACE  AFFECTIONS 

MIDDLE  EAR  DISEASE 

The  tympanic  chamber  or  middle  ear  is  a  region  of  great 
clinical  importance  in  children  because  of  the  frequent  infections 
to  which  it  is  subjected.  It  will  be  recalled  that  the  tympanum  is 
in  direct  communication  with  the  nasopharynx  through  the  Eustach- 
ian  tube;  hence,  in  inflammatory  conditions  of  the  throat  and  nose 
— diphtheria,  scarlet  fever,  measles,  tonsillitis,  postnasal  adenoids, 
etc. — the  infection  may  extend  into  the  middle  ear  and  produce 
changes  in  the  structures  which  seriously  impair  the  hearing,  or  a 
suppurative  condition  may  be  inaugurated  (suppurative  otifis 
media),  which  will  lead  to  grave  consequences. 

In  abscess  of  the  tympanum,  if  not  evacuated  by  surgical  inter- 

« 
vention,  the  membrane  may  rupture  spontaneously  and  the  pus  be 

discharged  through  the  external  meatus;  or  the  infection  may 
travel  through  the  roof  of  the  tympanum,  causing  meningitis  and 
intracranial  abscess.  It  may  travel  through  the  tympanic  floor, 
involving  the  internal  jugular  vein  and  causing  septic  thrombo- 
phlebitis; caries  of  the  anterior  walls  has  been  followed  by  ulcera- 
tion  into  the  carotid  artery  and  fatal  hemorrhage.  Caries  of  the 
Fallopian  canal  is  often  followed  by  permanent  facial  paralysis. 

Disorganization  of  the  internal  ear  leads  to  permanent  deafness ; 
while  infection  of  the  mastoid  antrum  and  cells  is  followed  by  mas- 
toiditis.  These  complications — so  serious  in  their  results — should  be 
thoroughly  appreciated,  and  it  should  be  further  understood  that 
their  treatment  is  not  within  the  province  of  the  general  prac- 
titioner, but  belongs  to  the  skilled  otologist. 

CHAPTER  XLVI 

FACE    AFFECTIONS 

VASCULAR   NEVUS 

Vascular  nevus  ("birth-mark,"  "port-wine"  mark)  is  a  vascular 
tumor  (angioma)  composed  of  capillary  vessels  of  abnormal  arrange- 


VASCULAR  NEVUS  365 

ment,  which  may  grow  and  develop  by  proliferation  and  new  forma- 
tion of  the  vessels.  These  nevi  are  due  to  developmental  disturb- 
ances and  are  found  near  the  embryonic  fissures — mouth,  eyebrows, 
cheek,  etc.,  and  are  not  infrequently  associated  with  other  congenital 
defects.  The  face  seems  to  be  a  site  of  predilection  for  these  con- 
genital tumors;  two-thirds  of  all  angiomata  are  found  here  and 
predominate  in  about  the  same  proportion  in  the  female  sex 
(V.  Bergmann). 

Varieties.  — The  simple  or  superficial  nevi  lie  in  the  skin  and 
consist  of  a  convolution  of  capillaries.  They  are  flat,  with  the  skin 
slightly  elevated,  and  present  a  red  or  bluish  red  patch  on  the 
skin  or  mucous  membrane  and  are  usually  noticed  at  birth  as  a 
cosmetic  defect.  They  may  remain  stationary  or  grow  with  great 
rapidity — and  involve  the  entire  half  of  the  face  in  a  few  months. 
Occasionally  they  disappear  spontaneously.  Compression  of  the 
affected  area  causes  the  blood  to  disappear,  but  it  promptly  returns 
when  the  pressure  is  removed.  Variations  in  blood  pressure  caused 
by  efforts  of  crying  or  the  reclining  position  modify  the  volume 
of  the  tumor. 

The  venous  nevi  (cavernous  angiomata)  are  true  vascular  neo- 
plasms which  are  composed  of  cavernous  spaces  bound  together  by 
delicate  connective  tissue  and  filled  with  blood.  They  are  usually 
subcutaneous,  but  the  skin  may  also  be  involved.  When  they  are 
confined  to  the  subcutaneous  tissue  they  appear  as  bluish,  trans- 
lucent, soft,  depressible  tumors,  which  are  emptied  by  compression, 
but  refill  when  released.  Coughing  or  straining  increases  their 
volume.  When  there  is  communication  with  an  artery  distinct 
pulsation  is  observed. 

Diagnosis. — There  is  little  difficulty  in  recognizing  the  nevi  by 
their  characteristic  appearance  and  the  fact  that  they  disappear  on 
pressure. 

Prognosis. — Every  nevus  may  on  occasion  grow  and  extend  with 
great  rapidity;  hence  the  necessity  for  very  early  treatment  to  pre- 
vent extension  and  consequent  deformity.  Spontaneous  cure  occurs 
only  through  injuries  to  the  surface,  which  produce  inflammatory 
reaction  with  subsequent  scar  formation,  yet  even  then  there 


366  FACE  AFFECTIONS 

may  remain  some  focus  from  which  an  angioma  may  develop  anew. 

Treatment. — When  the  nevus  is  situated  in  parts  of  the  body 
where  excision  can  be  performed,  it  is  unquestionably  the  most 
rapid  and  effective  method.  The  incision  is  made  wide  of  the 
growth,  and  hemorrhage  is  avoided  by  well-planned  digital  com- 
pression. The  larger  vessels  are  ligated,  sutures  are  so  placed  that 
they  include  the  depth  of  the  wound  and  thus  prevent  the  formation 
of  hematoma  and  subsequent  bleeding.  Where  the  shorter  radical 
operation  is  not  expedient  (angioma  of  the  face)  and  in  superficial 
nevi  it  is  better  to  adopt  those  me'asures  which  produce  inflamma- 
tory reaction  and  subsequent  scar  formation  and  which  are  applied 
at  repeated  sittings. 

Pacquelin  Cautery. — Multiple  scarifications  are  done  by  this 
means  at  repeated  sittings.  While  the  treatment  is  slow,  the  scars 
are  flat  and  not  unsightly. 

Liquid  Carbon  Dioxid. — The  treatment  with  liquid  carbon 
dioxid  is  most  satisfactory  in  superficial  nevi.  It  is  sprayed  on 
the  surface  for  ten  or  twenty  seconds,  and  after  several  repetitions 
of  the  treatment  at  weekly  intervals  the  nevus  disappears  with  a 
scar  that  is  scarcely  visible. 

Magnesium  Needles. — In  nevus  of  the  face  that  cannot  be 
operated  or  that  grows  into  the  deeper  tissues  and  cannot  be  reached 
by  extirpation,  Spitzy  advocates  the  introduction  of  magnesium 
needles  into  the  tumor.  The  needles  are  introduced  through  small 
skin  incisions  and  are  distributed  throughout  the  tumor.  The 
absorption  of  the  magnesium  results  in  scar  formation  and  the 
destruction  of  the  angiomatous  tissues. 

X-Ray  and  Radium. — It  must  be  remembered  that  the  use  of 
the  X-ray  and  radium  has  given  excellent  results  in  nevi  that  did 
not  permit  operation.  Spitzy  has  cured  an  angioma  of  the  upper 
lip  without  great  scar  formation  after  a  few  treatments  with  radium 
in  the  mouth. 

Injection  of  Irritating  Fluids. — Lastly,  it  must  be  emphasized 
that  the  injection  of  irritating  fluids  such  as  alcohol,  carbolic  acid, 
iodin,  etc.,  is  not  a  safe  procedure  and  should  be  regarded  as  an 
obsolete  method  of  the  preantiseptic  era. 


LYMPHANGIOMAS  OF  THE  FACE        3G7 


LYMPHANGIOMAS  OF  THE  FACE 

We  occasionally  find  on  the  face  of  infants  a  diffuse  hyper- 
trophy of  the  soft  parts,  notably  the  eyelid,  check,  and  lips.  They 
may  be  circumscribed  or  diffused.  They  are  soft  tumors,  intimately 
connected  with  the  skin,  which  is  normal  in  appearance,  grow  slowly, 
and  are  painless.  These  tumors  are  similar  in  structure  to  the 
hemangiomas — only  the  lymphatic  vessels  are  involved  and  pre- 
sent either  a  cavernous  arrangement,  in  which  the  cavities  communi- 
cate with  one  another,  or  a  grape-like  structure  formed  of  one  or 
more  cysts. 

Lymphangioma  of  the  Eyelids. — Lymphangioma  of  the  eyelids  is 
a  rare  condition  and  may  involve  the  eyelids  of  both  eyes  or  be  con- 
fined to  one  eye.  The  lesion  most  frequently  affects  the  two  upper 
eyelids.  In  Froelich's  case  the  upper  lids  were  greatly  increased 
in  volume  and  well  circumscribed;  the  color  of  the  skin  over  the 
tumor  was  more  pigmented  than  the  skin  of  the  face.  The  tumor 
was  brawny,  neither  compressible  nor  reducible,  and,  with  the  ex- 
ception of  the  deformity,  gave  no  disturbance.  It  is  evident 
that  when  the  lesion  is  in  the  lower  lid  and  well  developed  it 
may  cause  an  ectropion  which  may  necessitate  operative  interven- 
tion. 

TREATMENT. — When  intervention  is  necessary  partial  excision 
and  electrolysis  must  be  employed. 

Lymphangioma  of  the  Lips  (Macrochcilia). — The  lesion  is  more 
frequently  seen  in  the  lips  than  in  the  eyelids.  It  may  entirely  sur- 
round the  lips  and  produce  an  ectropion  of  the  mucosa.  In  marked 
cases  of  macrocheilia  the  development  of  the  upper  and  lower  jaw 
may  be  interfered  with  (V.  Bergmann). 

The  special  site  of  predilection  is  the  upper  lip,  which  it  usually 
involves  in  toto.  The  upper  lip  projects  forward  and,  in  extreme 
cases,  it  may  overhang  and  extend  in  front  of  the  lower  lip  as  far 
as  the  chin.  This  tumor  must  be  differentiated  from  angioma  of 
the  Up  by  the  unchanged  condition  of  the  skin.  Discoloration  of 


3G8 


FACE  AFFECTIONS 


the  skin  indicates  the  presence  of  blood  vessels.  Besides  angiomas 
are  compressible  and  reducible. 

TREATMENT. — When  the  size  of  the  tumor  produces  a  marked  de- 
formity it  i,s  necessary  to  resort  to  excision.  It  is  obvious  that 
operative  interference  here  is  difficult,  owing  to  the  small  size  of 
the  parts  and  the  improbability  of  removing  all  the  tumor-tissue. 
The  most  satisfactory  results  are  obtained  by  wedge-shaped  ex- 
cisions from  the  diseased 
lip. 

Lymphangioma  of  the 
Tongue  (  Macroglossia )  .— 
Lymphangioma  of  the  tongue 
is  a  congenital  condition 
which  affects  the  anterior 
three-fourths  of  the  tongue 
and  may  attain  enormous 
proportions.  (Fig.  120.) 
The  affection  at  birth  may  be 
noted  only  by  the  difficulty 
which  the  infant  has  in  nurs- 
ing, and  it  is  necessary  to 
nourish  these  children  by  a 
spoon  or  nursing  bottle.  As 
the  tongue  increases  in  size 
it  finally  protrudes  from  the 
mouth  and  cannot  be  reduced 

without  causing  suffocation.  Marked  changes  are  now  produced  in 
the  tongue  and  the  lower  jaw.  The  tongue  is  now  exposed  to  various 
irritations,  the  papillae  hypertrophy,  and  it  becomes  dry  and  black 
and  cracked.  The  pressure  of  the  teeth  causes  ulcerations.  Froelich 
has  described  a  case  in  which  the  incisor  teeth  finally  cut  the  pro- 
truding portion  so  deeply  that  it  became  gangrenous.  More  fre- 
quently the  pressure  of  the  tumor  upon  the  incisors  and  canine 
teeth  may  cause  them  to  project  forward. 

The  lower  jaw  is  likewise  modified  by  pressure,  so  that  it  is 
everted  and  a  median  depression  is  formed  from  which  the  saliva 


FIG.  120. — MACROGLOSSIA.  (After  Owen.) 


DEKMOID  CYSTS  OF  THE  FACE         ;$<><) 

is  constantly  dribbling.  It  is  obvious  that  mastication  is  quite 
impossible,  and  the  child  must  be  nourished  by  introducing  fluids 
behind  the  projecting  mass.  Phonation  is  likewise  defective,  and  in 
Froelich's  case  was  reduced  to  incomprehensible  guttural  sounds. 

TREATMENT. — Early  incision  before  later  complications  and  de- 
formity of  the  jaw  take  place.  Remove  a  V-shaped  piece  from 
the  anterior  part  of  the  tongue  and  suture  the  sides  of  the  wound 
together. 


DERMOID   CYSTS   OF   THE   FACE 

While  these  cysts  are  most  frequently  found  about  the  upper 
margin  of  the  orbit,  they  are  also  found  at  the  root  of  the  nose, 
in  the  periauricular  region,  and  on  the  neck.  These  cysts  are  small 
when  first  observed,  because  their  superficial  situation  exposes  them 
to  early  observation.  Sometimes  these  cysts  are  present  at  birth, 
others  do  not  develop  till  later. 

Cysts  near  the  orbit  are  most  frequently  situated  over  the  ex- 
ternal angular  process  of  the  frontal  at  the  level  of  the  fronto- 
maxillary  fissure.  Occasionally  they  penetrate  into  the  cavity 
of  the  orbit.  Their  extirpation  is  easily  accomplished  by  an 
incision  over  the  line  of  the  eyebrow  to  avoid  a  visible  scar. 
It  may  be  necessary  to  chisel  out  its  bony  implantation  when  the 
cyst  is  firmly  adherent.  Cysts  at  the  inner  angle  of  the  orbit  are 
less  frequent. 

Cysts  at  the  root  of  the  nose  may  be  easily  mistaken  for  menin- 
gocele;  the  latter,  however,  is  present  at  birth,  while  the  cysts  ap- 
pear later ;  the  cyst  is  not  reducible  and  does  not  become  tense  when 
the  child  cries. 

Periauricular  cysts  arc  situated  either  in  front  of  the  external 
auditory  meatus  or  over  the  mastoid  region.  The  latter  are  not  un- 
common. 

Cysts  of  the  cheek  correspond  in  position  to  the  intermaxillary 
cleft.  They  are  usually  situated  at  the  anterior  border  of  the 
masseter. 


370  OEAL  AFFECTIONS 

Diagnosis. — The  typical  situation  of  these  cysts  as  described 
above  is  of  itself  significant.  The  skin  is  freely  movable  over  the 
tumor,  the  surface  is  smooth  without  lobulation,  their  consistency 
is  doughy.  They  are  usually  small,  though  they  may  acquire  large 
dimensions.  They  grow  very  slowly.  The  tumor  is  usually  ad- 
herent and  fixed  by  a  pedicle  to  the  underlying  bone.  It  will  be 
necessary  to  differentiate  dermoid  cysts  from  sebaceous  cysts.  The 
latter  are  adherent  to  the  overlying  skin  and  freely  movable  on  the 
underlying  structures.  The  lipomata  are  more  rare,  and  are  dis- 
tinguished by  their  greater  volume,  flabbiness,  and  lobulation. 

Treatment.- — Complete  extirpation  which  includes  the  pedicle; 
otherwise  the  cyst  may  return. 

CHAPTER  XLVII 

ORAL    AFFECTIONS 

FOREIGN   BODIES   IN    THE   NOSE 

The  same  variety  of  small  objects  are  introduced  into  the  nose 
as  in  the  ear — beans,  beads,  buttons,  etc.  Insects  may  also  make 
their  way  into  the  nasal  fossae.  When  foreign  l)ody  is  suspected, 
confirm  the  suspicion  by  direct  examination  with  speculum  and 
head  mirror. 

Treatment. — Induce  the  child  to  sneeze  by  tickling  the  opposite 
nostril.  If  this  is  not  successful  try  vigorous  syringing  with  warm 
water.  In  complicated  cases  secure  if  possible  the  services  of  a 
rhinologist.  It  may  be  necessary  to  anesthetize  the  child  and  re- 
move the  foreign  body  by  instrumentation.  Foreign  bodies  per- 
manently lodged  in  the  nasal  fossa?  cause  ulceration  and  chronic 
suppuration. 

\ 

HARELIP 

Clinical  Picture. — Hare-lip  is  a  congenital  fissure  or  cleft  of  the 
lip  due  to  arrest  of  development.  The  lower  lip  develops  from  two 


HAEELIP 


371 


centers  which  fuse  in  the  median  line  and  a  congenital  fissure  of 
the  lower  lip  rarely  occurs.  The  upper  lip  develops  from  three 
centers:  a  median,  represented  by  the  frontonasal  process,  and  two 
lateral,  corresponding  to  the  superior  maxillary  processes.  When 
these  processes  fail  to  unite  on  one  or  both  sides  of  the  frontonasal 
process  there  results  a  unilateral  or  bilateral  (single  or  double) 
harelip  (Fig.  121).  The  failure  of  these  fissures  to  close  may  be 
due  to  some  mechanical  or  pathological  obstruction ;  they  are  de- 
velopmental defects  in  which  rachitis  or  increased  intracranial 
pressure  may  play  an  important  role. 

Note  that  hare-lip  is  a  lateral  cleft,  not  a  median  one.     The 
deformity  may  consist  only  of  a  notch  in  the  upper  lip,  or  it  may 


FIG.      121. — A.     UNILATERAL  HAKE-LIP.     B.     BILATERAL  HARE-LIP. 

extend  up  into  the  nostril  and  be  associated  with  a  cleft  palate.  It 
is  more  common  on  the  left  side. 

In  double  hare-lip  the  median  portion  of  the  lip  may  be  at- 
tached with  the  intermaxillary  bone  to  the  projecting  nasal  septum 
(persistent  fetal  type),  since  the  intermaxillary  bone,  the  nasal 
septum,  and  the  median  portion  of  the  lip  are  developed  from  the 
same  center. 

The  intermaxillary  bone  contains  the  germs  of  the  incisor  teeth. 
The  fissure  in  hare-lip,  therefore,  corresponds  to  the  interval  be- 
tween the  lateral  incisors  and  the  canine  teeth.  When  the  fissure 
extends  into  the  nasal  cavity  the  ala  of  the  nose  loses  its  normal 
arch  and  is  flattened  out.  The  red  border  of  the  lip  is  not  inter- 
rupted but  is  drawn  up  into  the  fissure  (see  Fig.  121).  When  the 
fissure  is  complete  it  extends  to  the  mucous  lining  of  the  nose. 


372  ORAL  AFFECTIONS 

Prognosis  differs  according  to  the  degree  of  the  fissure.  Hare- 
lip is  not  only  a  most  unsightly  deformity,  but  the  function  of  the 
lip  is  compromised  so  that  nutrition  is  imperfect,  the  child  is  unable 
to  suckle  the  breast  and  must  be  fed  with  a  spoon,  and  deglutition 
is  only  partially  performed,  as  a  portion  of  the  milk  is  regurgitated 
by  the  nares.  The  absence  of  the  nasal  filters  exposes  the  child  to 
infection  and  respiratory  troubles,  and  later  phonation  is  seriously 
embarrassed. 

Early  closure  of  the  lip  guarantees  the  normal  direction  in 
growth  of  the  intermaxillary  bone;  an  open  lip  encourages  an  ex- 
cessive growth  of  the  intermaxillary  bone  in  the  direction  of  the 
opening. 

Luckily  hare-lip  is  such  an  ugly  deformity  that  parents  are  im- 
pelled by  feelings  of  pride  to  have  the  defect  promptly  repaired. 
The  operation,  as  a  rule,  is  well  borne  by  children  and  the  mortality 
is  extremely  low.  With  modern  surgical  technique  and  a  rapid 
operator  the  dangers  of  operation  are  almost  nil. 

Operation. — At  what  age  should  the  operation  be  performed  ? 
The  best  time  to  operate  is  as  soon  after  birth  as  possible.  Nothing 
is  gained  by  delay  except  the  consequences  of  faulty  nutrition.  The 
earlier  the  operation  the  more  plastic  the  tissues  and  the  more  rapid 
the  repair.  The  vessels  in  the  newly-born  are  small,  hence  the  loss 
of  blood  is  slight,  the  risk  to  life  trivial. 

Xo  preparation  for  operation  is  necessary.  The  mucosa  is  only 
devitalized  by  the  use  of  antiseptic  fluids.  It  is  necessary  only  to 
have  the  face  clean. 

The  aim  of  the  surgeon  in  this  operation  is  to  restore  the  lip 
to  its  natural  form.  A  simple  freshening  of  the  edges  and  closure 
of  the  fissure  will  not  give  a  satisfactory  cosmetic  result,  since  the 
sequel  of  such  a  procedure  is  invariably  a  notch  in  the  free  border 
of  the  lip,  which  remains  as  evidence  of  the  original  deformity. 
To  avoid  this  a  plastic  operation  is  essential,  planned  to  meet  the 
different  conditions  which  each  case  presents. 

For  example,  in  dealing  with  a  simple  notch  in  the  border  of 
the  lip  a  transverse  incision  is  made  above  the  notch,  the  lip  drawn 
down  so  as  to  convert  the  transverse  into  a  vertical-shaped  opening, 


and  the  sutures  applied  in  this  direction.     Thus   the  deplh  <>f  the 
lip  is  increased  and  the  lahial  border  remains  intact.     (Fiji;.   \-2~2.) 

When  the  fissure  involves  the  entire  lip,  incisions  arc  made  on 
each  side  of  the  cleft  from  the  nose  down  to  the  line  of  the  lip,  leav- 
ing the  bases  of  the  flaps  attached.  The  two  flaps  are  drawn  down, 


B 


D 


FIG.  122. — STEPS  IN  OPERATION  FOR  SIMPLE  NOTCH  IN  BORDER  OF  THE  LIP. 
A.    Dotted  line  of  incision.     B.  Transverse  incision  completed.     C.  Transverse   con- 
verted into  a  vertical  opening.     D.  Line  of  sutures  completes  the  operation. 

the  freshened  edges  united  by  suture  so  that  there  will  result  a 
normal  eminence  at  the  free  border  of  the  lip.  (Fig.  123.)  What- 
ever operation  be  devised  to  meet  the  needs  of  the  individual  case 
the  following  points  should  be  noted: 


FIG.  123.— STEPS  IN  OPERATION  FOB  COMPLETE  FISSURE  OF  THE  LIP. 
A.    Line  of   incision  on  each    side  of  the  cleft.     B.  The  two  flaps  drawn  down.     C. 
Union  of  freshened  edges  by  a  vertical  suture  line. 

(a)  Anesthesia  is  not  only  unnecessary  but  it  is  attended  with 
a  certain  amount  of  danger. 

It  is  quite  satisfactory  to  have  the  patient's  arms  covered  with 
a  sheet  and  held  by  an  assistant  in  the  upright  position.  This 


374  ORAL  AFFECTIONS 

position  lessens  the  bleeding  and  gives  the  operator  an  opportunity 
to  observe  the  lines  of  the  face  and  plan  for  the  best  cosmetic 
results. 

Bleeding  may  be  controlled  by  the  fingers  of  an  assistant  com- 
pressing the  coronary  arteries  if  -necessary.  The  use  of  artery 
clamps  is  not  advised  since  the  vitality  of  the  tissue  is  thus  impaired 
by  pressure  necrosis.  The  loss  of  blood  will  not  be  serious  if  the 
incisions  are  exact  and  executed  with  rapidity. 

(b)  The  first  essential  step  in  the  operation  is  to  free  the  soft 
parts  from  the  bone.      This   should  be  done  thoroughly   so   as   to 
permit  normal  coaptation  without  any  pulling. 

(c)  The  incisions  should  be  exact,  well  defined,  and  present  as 
broad  a  surface  as  possible  for  coaptation. 

(d)  The  sutures  should  be  of  silk  or  linen  thread  and  embrace 
the  entire  thickness  of  the  lip  down  to  but  not  including  the  mucosa. 
These  sutures  must  not  be  tied  so  tight  as  to  cut  through  or  compress 
the  tissues.    Be  sure  that  the  suture  line  is  so  exact  that  it  presents 
no  pockets  for  the  collection  and  decomposition  of  food. 

(e)  Dress  the  wound  with  collodion  painted  over  gauze. 
After-treatment.  — For  the  first  twenty-four  hours  give  only  sterile 

water.  It  is  not  a  good  plan  to  feed  milk  until  the  injured  mucosa 
is  sealed  up  by  the  products  of  repair,  since  milk  is  a  good  medium 
for  bacteria  and  the  mouth  is  difficult  to  cleanse.  Milk  diet  may 
be  given  on  the  second  day,  always  following  the  feeding  by 
sterile  water  to  wash  away  the  milk  remnants.  The  dressing 
should  remain  in  place  for  seven  days,  when  the  sutures  may  be 
removed. 

It  is  well  to  protect  the  wound  from  the  child's  fingers  by 
splintering  the  arms.  The  habit  of  sucking  the  fingers  is  a  menace 
to  perfect  results. 

In  BILATERAL  HAKE-LIP  the  greatest  difficulty  in  closing  the 
fissure  is  sometimes  caused  by  the  protrusion  of  the  intermaxillary 
bone.  In  early  operation  this  difficulty  is  rarely  encountered,  the 
pressure  of  the  lip  after  closure  causes  the  bone  to  assume  its  normal 
direction.  In  neglected  cases  it  may  be  necessary  to  force  the  pro- 
truding bone  back  into  the  fissure.  The  projecting  intermaxillary 


CLEFT  PALATE  375 

bone  must  be  gotten  into  line  so  as  to  be  on  the  same  level  as  the 
adjacent  alveolar  borders  of  the  maxillary  bones. 

It  must  be  remembered  that  the  intermaxillary  bone  carries  the 
incisor  teeth  and  that  it  should  be  removed  only  under  great  provo- 
cation. In  its  absence  the  upper  lip  is  depressed  and  the  deformity 
is  only  overcome  by  a  bridge  of  teeth.  Besides,  the  removal  of  this 
process  seriously  compromises  the  development  of  the  nasopharynx, 
arrests  the  normal  growth  of  the  upper  jaw  and  thus  impairs  the 
function  of  normal  respiration  and  the  vital  capacity  of  the  indi- 
vidual. 

CLEFT  PALATE 

Etiology  and  Pathology. — Cleft  palate  is  a  congenital  gap  in  the 
palate  due  to  arrest  of  development  and  can  be  understood  only  by 
an  intelligent  appreciation  of  the  changes  which  take  place  in  the 
formation  of  the  nasal  and  buccal  cavities  during  fetal  life.  Recall 
the  fact  that  in  early  fetal  life  the  nasal  and  buccal  cavities  are 
one;  the  formation  of  a  partition  between  these  two  cavities  is  only 
accomplished  by  the  development  of  the  palate,  which  is  formed 
by  the  palatal  plates  of  the  superior  maxillary  bones,  and  the  palate 
bones  growing  horizontally  inward  on  each  side,  meeting  in  the 
median  line  and  thus  closing  the  fetal  gap  between  the  two  cavities. 

Again,  note  that  the  fusing  of'lHe.  palatal  plates  does  not  form 
a  complete  partition;  there  still  remains  a  V-shaped  interval  in 
front,  the  apex  of  which  is  at  the  anterior  palatine  canal,  the  sides 
extending  to  the  interval  between  the  lateral  incisor  and  canine 
teeth.  (Fig.  124.)  This  interval  is  filled  by  the  intermaxillary 
bones  which  are  developed  from  the  frontonasal  process  forming 
the  septum  of  the  nose. 

With  these  facts  in  mind  it  is  readily  seen  that  an  arrest  of 
development  may  produce  a  median  gap  or  cleft  which  varies  in 
degree  from  a  notch  in  the  soft  palate  to  a  complete  gap  involving 
both  the  soft  and  hard  palates  as  far  as  the  anterior  palatine  canal. 
If  the  cleft  extends  beyond  this  point  and  involves  the  alveolar 
margin  it  leaves  the  median  line  and  follows  the  suture  line  of  the 


376 


OEAL  AFFECTIONS 


FIG.    124. — NOTE    THE    V-SHAPED  INTERVAL 

FILLED   BY    THE    INTERMAXILLARY   BONE. 
A.     Median   articulation.     B.     Intermaxillary 
bone. 


intermaxillary  bone,  the  an- 
terior extremity  of  the  cleft 
appearing  between  the  lat- 
eral incisor  and  canine 
teeth.  (Fig.  125.)  If  the 
cleft  involves  only  one  side 
of  the  intermaxillary  bones 
single  hare-lip  is  usually 
present,  if  it  involves  both 
sides  of  the  intermaxillary 
bones  double  hare-lip  is  pro- 
duced and  the  intermaxil- 
lary bones  are  attached  to 
the  tip  of  the  nose. 

Every  form  of  cleft  pal- 
ate can  exist  alone  or  in 
conjunction  with  hare-lip. 
It  is  obvious  that  this  condition  is  a  serious  menace  to  the  nutrition 
of  the  infant,  since  it  is  impossible  for  the  child  to  suckle  or  satis- 
factorily swallow  the  food  introduced  into  the  mouth.  The  food 
often  regurgitates  through  the  nose  and  endangers  respiration.  Chil- 
dren with  cleft  palate  should  be  fed  in  the  upright  position  so  that 
the  fluid  will  gravitate 
directly  into  the  pharynx. 
Later,  articulation  and 
phonation  are  seriously 
compromised — the  defec- 
tive nasopharyngeal  wall 
permits  the  air  current  to 
escape  through  the  nose 
and  makes  the  distinct 
articulation  of  consonants 
impossible.  The  tools  of 
speech  must  be  normal  in 

order  to  have  correct 

FIG.    125. — COMPLETE    CLEFT    INVOLVING    HARD 
Speech.       JNot    only    this,  AND  SOFT  PALATES. 


CLEFT  PALATE  377 

but  unless  the  mouth  and  nasal  cavities  are  separated  early  in  life 
normal  physiological  function  is  impossible:  hence,  normal  develop- 
ment is  seriously  compromised,  vital  capacity  is  impaired,  the 
physiognomy  is  altered,  and  the  individual  is  physically  and  intel- 
lectually a  defective. 

Treatment. — As  Lane  observes,  "the  treatment  of  cleft  palate  has 
been  a  matter  of  creed  and  tradition  and  has  not  been  arrived  at 
in  any  reasonable  manner."  Fortunately  surgeons  are  beginning 
to  appreciate  that  the  old  dictum  of  delay  has  nothing  to  commend 
it.  It  is  fallacious  in  premise  and  conclusion.  If  the  normal  de- 
velopment of  the  nasopharynx  and  the  surrounding  structures  de- 
pends upon  its  normal  physiology  it  is  obvious  that  the  nose 
and  mouth  cavities  should  be  separated  as  early  as  possible.  The 
child  cannot  develop  so  long  as  its  supply  of  air  and  food  is  de- 
ficient. 

The  proper  time  to  operate  for  cleft  palate  is  as  soon  after  birth 
as  possible. 

The  plasticity  of  the  new-born  tissues,  their  capacity  for  repair, 
the  trifling  hemorrhage,  the  slight  risk  to  life,  the  possibility  of 
obtaining  a  broad  well  vascularized  flap  before  the  teeth  have  begun 
to  encroach  upon  the  mucous  membrane  combine  to  make  early 
infancy  an  opportune  time  for  repairing  this  defect.  The  opera- 
tion devised  by  Lane  is  ingenious,  rational,  and  satisfactory,  and 
far  superior  to  the  usual  method  of  freshening  the  edges  of  the 
cleft  and  bringing  them  together,  or  the  complicated  method  of 
Brophy,  who  approximates  the  two  superior  maxillary  bones  by 
means  of  silver  wire  and  adjusts  the  vivified  edges  of  the  cleft  with 
sutures. 

THE  "LANE  OPERATION." — The  principle  of  this  operation  is 
"to  close  in  the  interval  between  the  edges  of  the  cleft  by  muco- 
periosteum  in  the  case  of  the  hard  palate,  and  by  mucous  membrane 
and  submucous  tissue  in  case  of  the  soft  palate."  The  features 
of  the  operation  are  the  breadth  of  the  flaps,  and  the  ingenious 
method  of  overlapping  them  so  that  the  fissure  is  closed  in  by  a 
curtain  of  tissue  on  which  there  is  no  tension  and  in  which  the 
play  of  the  muscles  is  unimpaired. 


378 


FIG.     126. — MOUTH-GAG    WITH    SHARP 
TEETH  THAT  BITE  INTO  THE  GUM. 


If  hare-lip  exists  the  defect  is 
repaired  at  the  same  time  as  the 
cleft  in  the  palate. 

Lane  under  no  circumstances 
ever  removes  the  intermaxillary 
bone  or  performs  any  operation 
upon  it  with  a  view  of  displacing 
it  backward.  "The  pressure 
which  is  exerted  upon  it  by  the 
lip  after  its  continuity  has  been 
effected  is  quite  sufficient  to 
bring  about  its  backward  dis- 
placement." 

Instruments. — Since  the  op- 
eration is  one  of  great  delicacy  it  is  impossible  to  employ  the  ordi- 
nary surgical  instruments  with  any  degree  of  satisfaction.  The 
operator  must  work  in  a  small  cavity  upon  tissues  that  are  easily 
torn  and  devitalized;  the  essentials  are  a  good  light,  complete  ex- 
posure, and  special  instruments  of  precision. 
These  should  consist  of  a  suitable  mouth  gag 
with  sharp  teeth  which  bite  into  the  gum  and 
will  not  slip  as  shown  in  Fig.  126 ;  a  knife 
with  a  small  blade  (Fig.  127) ;  small  curved 
elevator  for  detaching  flaps;  small  round  in- 
testinal needles,  a  needleholder  with  small  jaws 
and  opposing  surfaces  that  are  serrated  so  as 
to  grip  the  needle  (Fig.  128)  ;  mouse-toothed 
thumb  forcep,  and  artery  clamps  for  controlling 
the  palatine  vessels. 

Very  fine  silk  is  used  for  the  sutures. 
The  anesthetic  employed  is  ether — the  drop 
method  with  Ferguson  cone. 

Operation. — It  is  obvious  that  in  the  clos- 
ure of  any  particular  cleft  the  surgeon  must 
be  largely  guided  by  his  experience,  and  that     FIG.  127.— CONVENIENT 
only  the  principles  and  a  general  description  of          BLADED  KNJVXS. 


CLEFT  PALATE 


379 


methods  can  be  given,  which  must  be  modified  to  suit  the  individual 
needs.  The  operation  as  described  by  Lane  is  as  follows:  ''The 
mouth  gags  are  placed  in  position  and  the  tongue  drawn  forward 
by  a  ligature  so  as  to  give  free  access  to  the  cleft  in  its  entire  length. 
If  the  soft  parts  overlying  the  edges  of  the  cleft  are 
thick  and  vascular  a  flap  is  cut  from  the  mucous 
membrane,  submucous  tissue,  and  periosteum  of  one 
side,  having  its  attachment  or  base  along  the  free 
margin  of  the  cleft.  The  palatine  vascular  supply  is 
divided  while  the  flap  is  being  reflected  inward,  and 
it  depends  for  its  blood  supply  on  vessels  entering 
its  attached  margin. 

"The  mucous  membrane,  submucous  tissue,  and 
periosteum  are  raised  from  the  opposing  margin  of 
the  cleft  by  an  elevator,  an  incision  being  made 
along  the  length  of  the  edge  of  the  cleft. 

"The  reflected  flap  with  its  scanty  supply  of 
blood  derived  from  small  vessels  in  its  attached  mar- 
gin is  then  placed  beneath  the  elevated  flap,  whose 
blood  supply  is  ample,  and  it  is  fixed  in  position  by 
a  double  row  of  sutures.  In  this  manner  two  ex- 
tensive raw  surfaces  well  supplied  with  bleod  and 
uninfluenced  by  any  tension  whatever  are  retained 
in  accurate  apposition. 

"If,  on  the  other  hand,  the  cleft  is  too  broad  to 
admit  of  its  safe  and  perfect  closure  in  this  manner, 
one  flap,  comprising  all  the  mucous  membrane,  sub- 
mucous  tissue,  and  periosteum  on  one  side,  is  raised 
except  at  the  point  of  entry  of  the  posterior  palatine 
vessels,  while  the  soft  parts  on  the  opposite  side  are  raised  in  a  flap 
from  which  the  posterior  palatine  has  been  excluded,  and  which 
pivots  on  a  base  formed  by  the  margin  of  the  cleft.  Here  we  have 
a  mobile,  well-vascularized  flap,  which  can  be  thrown  as  a  bridge  in 
any  direction  and  can  be  superimposed  on  the  flap  of  the  opposite 
side,  the  closure  being  necessarily  rendered  complete  by  flaps  from 
the  edges  of  a  hare-lip." 


FIG.  128. — LANE 
NEEDLE -HOLD- 
ER AND  NEE- 
DLES. 


380 


ORAL  AFFECTIONS 


This  method  may  be  best  illustrated  diagrammatically  as  indi- 
cated in  Fig.  129,  which  represents  the  roof  of  the  mouth  with  a 
cleft  extending  through  the  hard  and  soft  palates.  The  alveolus  is 
indicated  by  A  A  A. 

The  operation  consists  in  introducing  a  reflected  flap  on  one 
side  beneath  a  raised  flap  of  the  opposite  side  as  follows: 

The  reflected  flap  is  made  by  the  incision  ab,  which  extends 
from  the  anterior  limit  of  the  cleft  forward  and  outward  through 
the  mucoperiosteum  to  beyond  the  outer  surface  of  the  alveolus; 


FIG.  129. — LINES  OF  INCISION  FOR  REPAIR  OF  A  MEDIAN  CLEFT  IN  INFANCY.  (Lane.) 

be  runs  along  the  outer  surface  of  the  gums  at  the  junction  of  the 
cheek  and  alveolus;  cd  extends  along  the  free  posterior  margin  of 
the  palate  to  the  uvula.  This  flap  is  carefully  raised  from  the 
underlying  structures,  the  posterior  palatine  vessels  and  nerves  being 
clamped  and  divided.  Its  attached  border  is  the  edge  of  the  cleft 
on  one  side,  and  as  it  is  reflected  over  the  cleft  its  mucous  surface- 
looks  upward. 

The  raised  flap  is  made  by  an  incision  ae  extending  on  to  tlio 
alveolus;  the  incision  af  courses  along  the  free  margin  of  the  cleft 
and  is  continued  as  fg,  obliquely  outward  and  backward  along 
the  upper  surface  of  the  soft  palate.  The  incision  gh  extends  along 
the  posterior  free  margin  of  the  palate  to  the  tip  of  the  uvula. 


CLEFT  PALATE 


381 


The  mucoperiosteal  flap  afg  is  now  raised  from  the  bone,  the  soft 
palate  freed  from  the  posterior  margin  of  the  hard  palate,  and  the 
mucous  membrane  on  its  upper  surface  turned  outward. 

The  completion  of  the  operation  consists  in  introducing  the  re- 
flected flap  of  one  side  beneath  the  raised  flap  of  the  opposite  side 


FIG.    130. — METHOD  OF  FIXATION  OF  THE  REFLECTED  FLAP  BENEATH  THE  ELEVATED 
FLAP  BY  A  DOUBLE  Row  OF  SUTURES.  (Lane.) 

and  the  two  fixed  in  position  by  a  double  line  of  sutures  as  shown 
in  Fig.  130.  The  completed  operation  with  dotted  suture  lines  is 
shown  in  Fig.  131. 

If  the  septum  presents  a  free  margin  which  extends  to  the  level 
of  the  cleft  (see  Fig.  129),  an  additional  incision  (1-2)  is  made  along 


Fio.  131. — FLAPS  SUTURED  IN  POSITION  FOR  REPAIR  OF  MEDIAN  CLEFT. 
the  middle  line  of  the  septum  through  the  mucous  membrane  and 
periosteum  with  two  transverse  incisions   (3-4  and   5-6). 

These  two  narrow  flaps  are  turned  down  laterally  and  the  re- 
flected flap  denuded  of  its  mucous  membrane  along  the  area  of 
contact  is  sutured  to  the  superimposed  flaps  and  the  margin  of 
the  septum  (Figs.  129  and  131)  (Lane). 

A  natural  objection  to  this  operation  is  the  large  area  of  raw 
surface  which  is  left.  It  is  surprising  how  rapidly  this  surface  is 


382 


OEAL  AFFECTIONS 


covered  over  by  new  tissue  and  the  normal  appearance  of  the  mucosa 
restored. 

This  general  principle  of  superimposed  flaps  is  applicable  to 
every  variety  of  cleft  palate,  it  is  modified  as  the  individual  needs 
and  ingenuity  of  the  surgeon  suggests  (Figs.  132  and  133) 


PIG.  132. — INCOMPLETE  CLEFT  PALATE  WITHOUT  HAKE-LIP  OPERATED  AT  FOURTH  WEEK.. 

After-treatment. — For  the  first  twenty-four  hours  give  only  sterile 
water.  Do  not  give  milk  until  the  injured  mucosa  is  sealed  up  by 
the  products  of  repair,  since  milk  is  a  good  medium  for  bacteria 
and  the  mouth  is  difficult  to  cleanse. 

Keep  the  child  quiet  and  try  to  prevent  crying. 

Milk  diet  may  be 
given  on  the  second  day. 
Always  follow  the  feed- 
ing with  sterile  water 
to  wash  away  the  milk 
remnants. 

No  mechanical 
cleansing  of  the  mouth 
is  practical  in  small 
children. 

On  the  seventh  day 

the     Sutures     should     be          FIG.  133. — HARE-LIP  AND  CLEFT  PALATE  OPERATED 

AT  THE  THIRD  WEEK. 
removed.  Result  at  nine  months. 


HYPERTEOPHIED  TONSILS  383 

RANULA 

Ranula  is  a  term  used  to  designate  those  cysts  in  the  sublingual 
region  which  are  due  to  an  obstruction  of  a  mucous  or  salivary 
gland.  This  condition  may  be  congenital  or  acquired.  It  is  most 
frequently  observed  between  the  seventh  and  tenth  years.  It  is 
usually  discovered  by  accident  as  a  small,  ovoid,  bluish-white  swell- 
ing, situated  on  one  side  of  the  tongue  and  usually  elevating  the 
floor  of  the  mouth. 

Varieties. — It  is  obvious  that  the  cyst  may  vary  somewhat  accord- 
ing to  the  structure  involved.  Thus  we  have  sublingual  ranula  due 
to  blocking  of  the  ducts  of  Rivini,  a  very  common  form,  which  may 
occasionally  be  large  enough  to  interfere  with  speech  and  deglutition. 

Submaxillary  ranula,  caused  by  an  obstruction  of  Wharton's 
duct.  If  the  obstruction  is  at  the  orifice  a  cylindrical  swelling  is 
produced  in  the  floor  of  the  mouth;  if  at  the  origin  of  the  duct, 
the  gland  itself  may  be  distended  and  present  a  swelling  beneath 
the  jaw. 

Incisive  ranula  is  a  dilatation  of  a  small  gland  adjacent  to  the 
frenum  at  its  junction  with  the  lower  jaw  (near  the  incisor  tooth). 

Blandins  ranula  is  due  to  an  obstruction  of  the  ducts  of  the 
glands  of  Blandin  or  Nuhn,  situated  on  the  inferior  surface  near 
the  tip  of  the  tongue. 

Weber's  ranula  is  a  dilatation  of  the  glands  situated  posteriorly 
on  the  lateral  border  of  the  tongue. 

Wherever  situated  ranula  is  characterized  by  its  indolent  symp- 
tomatology and  the  diagnosis  is  extremely  easy. 

Treatment. — Total  extirpation  wherever  possible.  This  is  easier 
said  than  done,  and  as  a  rule  it  will  be  possible  to  dissect  out  only 
a  portion  of  the  cyst  wall,  the  remainder  is  painted  with  tincture 
of  iodin  and  the  wound  packed  with  gauze  for  twenty-four  hours. 

HYPERTROPHIED   TONSILS 

The  etiology  and  symptomatology  of  enlarged  tonsils  are  too  well 
known  and  also  ably  described  in  special  literature  to  need  eluci- 


384  ORAL  AFFECTIONS 

elation  here.  But  there  are  certain  rather  well-defined  indications 
for  their  removal  that  must  be  appreciated.  Not  every  livpcv- 
trophied  tonsil  is  evidenced  by  an  enlargement  that  can  be. plainly 
seen.  In  fact,  many  of  the  worst  cases  are  those  in  which  the 
tonsil  is  buried  and,  to  superficial  examinations,  does  not  seem  to 
be  enlarged.  Their  removal  is  advisable: 

(a)  When  the  child  suffers  repeated  attacks  of  tonsillitis. 

(b)  When  there  is  a  nasal  or  deficient  articulation. 

(c)  When  deafness  or  repeated  attacks  of  earache  are  present 
and  other  causes  can  be  reasonably  eliminated. 

(d)  When  there  is  obstruction  to  free  breathing,  with  or  with- 
out the  consequent  deforming  effects  upon  the  chest. 

In  every  instance  the  examination  must  include  the  determina- 
tion of  whether  adenoids  exist  also.  Adenoid  vegetations  are  found 
in  nearly  every  instance  in  which  the  tonsils  are  chronically  hyper- 
trophied. 

Complete  removal  is  always  preferable.  The  danger  from  the 
operation  is  practically  limited  to  that  of  hemorrhage,  which  has 
been  excessive  in  a  few  instances. 

ADENOID   VEGETATIONS 

There  is  but  one  method  by  which  these  growths  may  be  detected, 
and  that  is  by  digital  examination.  While  there  are  many  symp- 
toms (as  deafness,  mouth  breathing,  snoring,  restless  sleeping,  the 
facial  expression,  etc.)  which  are  suggestive,  the  digital  examina- 
tion is  the  only  positive  means  of  determination.  The  finger  should 
completely  explore  the  rhinopharynx. 

In  infants,  when  digital  examination  is  impractical,  more  de- 
pendence has  to  be  placed  upon  the  inability  to  properly  nurse  and 
the  evidences  of  obstructive  breathing.  However,  in  determining 
this  as  due  to  adenoids,  the  surgeon  must  eliminate  the  possibility 
of  occlusion  of  the  nostril,  deformity  of  the  palate,  acute  rhinitis, 
retropharyngeal  abscess,  pharyngeal  paralysis,  nasal  diphtheria,  en- 
larged cervical  glands,  enlarged  thyroid  gland,  and  the  local  effects 
(in  the  nose  and  pharynx)  of  tuberculosis  and  syphilis. 


EETEOPHARYNGEAL  ABSCESS  385 

When  detected  their  removal  is  advisable  if  they  are  the  cause 
of  symptoms  and,  in  many  instances,  the  removal  of  the  accompany- 
ing hypertrophied  tonsils  is  indicated  also  to  make  the  relief  com- 
plete. 

The  after-care  of  children  who  have  been  operated  upon  for  the 
removal  of  either  adenoids  or  hypertrophied  tonsils  is  no  small 
part  of  the  treatment,  and  its  neglect  tends  to  bring  the  procedure 
into  disrepute. 

When  these  enlargements  have  caused  symptoms  they  are  usually 
marked  ones  before  an  operation  is  consented  to,  and  the  child  is 
far  below  its  normal  efficiency.  This  must  be  corrected  by  the  ad- 
ministration of  suitable  tonics  and  the  regulation  of  the  diet  and 
general  hygiene  of  the  child  before  and  after  the  operation.  Cer- 
tain definite  exercises  are  in  nearly  every  instance  necessary  to  over- 
come the  deformities  which  have  been  the  result  of  the  obstructed 
breathing. 


RETROPHARYNGEAL   ABSCESS 

The  formation  of  an  abscess  behind  the  posterior  pharyngeal 
wall  is  a  special  affection  of  childhood.  More  than  one-half  the 
cases  occur  during  the  first  year  (V.  Bergmann).  It  is  an  extremely 
grave  affection  and  may  prove  fatal  unless  there  is  timely  inter- 
vention. 

Etiology. — Besides  the  chronic  tuberculous  abscess  in  the  retro- 
pharyngeal  space,  which  may  result  from  disease  of  the  cervical 
vertebra},  we  encounter  the  acute  abscess,  due  to  suppuration  of 
the  lymph  glands,  situated  behind  the  pharynx  and  along  the  cervical 
vertebra.  The  infection  is  carried  from  the  mucous  membrane 
of  the  nasal  fossa?,  the  nasopharynx,  or  the  middle  ear  during  the 
course  of  measles,  scarlet  fever,  whooping  cough,  bronchopneu- 
monia,  and  tonsillitis. 

Symptoms. — The  symptoms  are  at  first  those  due  to  inflammatory 
reaction  and  septic  absorption,  and  second  those  due  to  functional 
disturbance.  Besides  the  pain,  fever,  and  swelling  there  are  diffi- 


386  ORAL  AFFECTIONS 

culty  in  swallowing,  disturbance  of  respiration,  and  changes  in  the 
voice. 

Dysphagia  is  caused  by  the  painful  movements  of  deglutition  and 
by  the  actual  obstacle  which  the  phlegmon  presents  to  the  passage  of 
food.  As  soon  as  the  child  attempts  to  swallow  the  fluid  is  im- 
mediately regurgitated  through  the  nose  or  mouth. 

Dyspnea. — Respiration  is  labored,  inspiration  is  accompanied 
by  a  wheezing  sound  indicating  an  obstruction  to  the  air  passages. 
The  voice  is  altered,  the  mouth  is  filled  with  mucus;  movements 
of  the  neck  are  painful,  and  there  is  marked  rigidity  of  the  muscles 
of  the  neck. 

Diagnosis. — It  is  not  rare  to  find  this  condition  overlooked 
simply  from  neglect  to  palpate  the  pharynx.  Never  fail  to  palpate 
the  pharynx  of  a  child  suffering  from  dysphagia  or  dyspnea.  By 
introducing  the  finger  into  the  mouth  and  directing  it  toward  the 
posterior  pharyngeal  wall  tumefaction  and  fluctuation  are  readily 
recognized. 

Prognosis. — Retropharyngeal  abscesses  left  to  themselves  usually 
result  in  death  from  asphyxia,  due  to  spasm  of  the  glottis  or  spon- 
taneous opening  of  the  abscess  and  the  sudden  precipitation  of  a 
quantity  of  pus  into  the  air  passages. 

Treatment. — Prompt  evacuation  of  the  abscess.  The  operation 
should  be  performed  without  delay  and  without  anesthesia.  The 
child  is  held  by  the  nurse  so  that  the  head  and  hands  are  im- 
mobilized. A  straight  bistoury  is  prepared  by  protecting  the  blade 
with  adhesive  plaster  to  within  a  quarter  of  an  inch  of  its  point. 
The  left  index  finger  is  introduced  to  the  point  of  fluctuation  and 
along  this  finger  the  knife  is  guided  to  the  posterior  pharyngeal  wall, 
in  which  an  incision  of  about  one-half  inch  is  made.  As  soon  as 
the  pus  escapes  the  child's  head  is  turned  directly  downward  to 
prevent  the  pus  from  entering  the  larynx. 

It  is  not  rare  after  the  incision  for  the  child  to  stop  breathing, 
but  artificial  respiration  with  the  head  low  usually  results  in  prompt 
restoration. 

The  operation  is  usually  curative  and  it  is  rarely  necessary  to 
reopen  the  wound  because  of  its  too  early  closure. 


FOKEIGX  BODIES  IX  THE  AIll  PASSAGES  387 

Retropharyngeal  abscess  may  be  opened  externally  by  a  cuta- 
neous incision  in  front  of  the  sternomastoid,  but  it  is  obvious  that 
such  intervention  implies  a  careful  dissection  under  anesthesia, 
and  is  not  to  be  considered  where  time  is  the  essential  factor  in 
saving  life. 


CHAPTER  XLVIII 

THE    AIR    PASSAGES 

FOREIGN   BODIES   IN   THE   AIR  PASSAGES 

Various  foreign  bodies  find  their  way  into  the  air  passages,  such 
as  peas,  beans,  beads,  buttons,  pins,  nails,  tacks,  toy  whistles,  etc. 
The  object  is  introduced  into  the  mouth,  and  aspirated  into  the 
air  tube  under  the  influence  of  sudden  inspiration  induced  by  laugh- 
ing or  coughing.  The  ultimate  destination  of  the  object  depends 
upon  its  size  and  shape.  Hough,  angular  bodies  are  usually  arrested 
in  the  larynx,  if  the  object  is  large  enough  to  completely  obstruct 
the  laryngotrachea.  According  to  Lenox  Browne  twenty  per  cent, 
of  foreign  bodies  are  arrested  in  the  larynx,  about  fifty  per  cent, 
pass  into  the  trachea,  and  about  twenty-five  per  cent,  lodge  in  the 
bronchi. 

Symptoms. — Whatever  the  foreign  body  may  be  it  produces  first 
an  initial  crisis  at  the  time  of  the  accident,  a  crisis  marked  by  con- 
vulsive cough,  suffocation,  cyanosis,  and  violent  vomiting.  During 
the  spasm  the  foreign  body  is  expelled,  or  death  may  supervene 
from  sudden  cardiac  or  respiratory  failure,  or  it  passes  the  glottis 
and  becomes  lodged  in  the  trachea  or  bronchus,  to  remain  for  a 
variable  time  quiescent,  interrupted  at  irregular  intervals  by  re- 
peated crises  of  cough  and  suffocation  as  the  foreign  body  is  moved 
about  by  the  changing  position  of  the  child. 

Crises  of  suffocation  may  occur  during  sleep. 

Auscultation  often  reveals  curious  vibratory  sounds.  When  a 
large  bronchus  is  plugged  there  is  absence  of  vesicular  murmur  in 
the  corresponding  part  of  the  lung. 


388 


THE  AIR  PASSAGES 


The  expectoration  is  at  first  mucous,  sometimes  tinged  with 
blood,  later  it  becomes  purulent.  Pain  is  rarely  produced  by  a 
foreign  body,  sometimes,  however,  it  may  be  localized  at  the  sternum 
or  in  the  back. 

Diagnosis  is  based  on  the  history  and  the  initial  crisis.  The 
X-ray  is  a  valuable  agent  in  accurately  locating  metallic  substances 
when  the  symptoms  are  not  urgent.  If  the  body  is  lodged  in  the 

larynx  it  may  be  detected  by  the 
laryngoscope;  if  below  the  larynx, 
bronchoscopy  should  be  employed. 

Prognosis. — While  it  is  rare  for 
the  initial  crisis  to  terminate  in 
death,  and  while  foreign  bodies  may 
be  tolerated  for  a  long  time  after  the 
accident,  pulmonary  complications 
always  threaten  a  fatal  termination. 
The  prognosis  is  therefore  grave. 

Treatment. — This  depends  upon 
where  the  foreign  body  is  located. 
//  the  symptoms  are  urgent  an  at- 
tempt may  be  made  to  remove  the 
body  by  introducing  the  finger  into 
the  mouth,  or  the  body  is  sometimes 
forcibly  expelled  by  inverting  the 


FIG.  134.— A.  THE  CRICOTHYROID  MEM-   patient    and    striking    him   on    the 
BRANE     THROUGH     WHICH     RAPID 
"TRACHEOTOMY"     MAY    BE     PER- 
FORMED. 


back.  If  not  immediately  success- 
ful do  a  laryngotomy  at  once.  Lar- 
yngotomy  consists  in  opening  the  larynx  through  the  cricothyroid 
membrane  by  a  transverse  incision  made  close  to  the  upper  border  of 
the  cricoid  cartilage.  (Fig.  134.)  It  is  the  simplest  and  quickest 
method  of  relieving  dyspnea  when  prompt  intervention  is  demanded. 
Where  the  symptoms  are  less  urgent  extraction  may  be  possible 
through  the  natural  passages  by  means  of  the  laryngoscope  and 
forceps,  but  preparations  for  an  instant  tracheotomy  should  always 
precede  these  manipulations  should  sudden  spasm  of  the  glottis 
demand  intervention. 


INTUBATION  38!) 

When  the  body  is  situated  below  the  larynx  a  tracheotomy  may 
be  performed.  It  is  not  unusual  to  see  a  foreign  body  expelled 
through  the  tracheotomy  wound  as  soon  as  the  trachea  is  opened 
and  before  the  tube  is  introduced. 

When  the  symptoms  are  not  urgent  the  child  should  be  placed 
under  the  care  of  one  who  is  skilled  in  laryngoscopy  and  bron- 
choscopy.  The  obsolete  method  of  blindly  groping  after  foreign 
bodies  is  not  justified  when  it  is  possible  to  obtain  the  services  of  one 
who  is  skilled  in  the  use  of  modern  instruments  of  precision. 


INTUBATION 

The  advantages  of  intubation  over  tracheotomy  are  its  simplicity 
and  the  rapidity  with  which  it  may  be  accomplished  without  any 
anesthetic,  and  for  these  reasons  chiefly,  it  has  practically  super- 
seded the  latter  operation  for  the  relief  of  laryngeal  diphtheria. 
It  is  an  operation  that  any  surgeon  may  be  called  upon  to  perform 
at  any  time,  and  as  the  symptoms  which  demand  its  performance 
are  usually  very  urgent,  familiarity  with  the  technique  is  necessary. 

The  procedure  may  be  necessary  not  alone  in  diphtheria  but  in 
a  retropharyngeal  abscess,  which  is  situated  low  on  the  posterior 
pharyngeal  wall,  in  edema  of  the  larynx,  or  acute  laryngitis. 

While  there  is  considerable  dispute  as  to  the  actual  need  or 
value  of  the  procedure  in  any  given  case,  it  may  be  stated  as  a  fact 
borne  out  by  repeated  clinical  experiences  that  the  operation  is 
usually  undertaken  too  late  rather  than  too  early  to  give  all  the 
relief  that  can  be  obtained.  It  is  a  safe  rule  to  give  precedence 
to  the  general  state  of  the  child  as  regards  exhaustion  and  fatigue 
in  its  struggles  for  air,  rather  than  to  the  more  commonly  accepted 
one  of  the  estimated  degree  of  stenosis  as  evidenced  by  recession  in 
the  suprasternal  and  infrasternal  regions.  Especially  in  diphtheria 
it  is  absolutely  essential  to  conserve  every  bit  of  strength,  and  thus, 
if  any  error  is  made,  it  should  be  upon  the  side  of  early  intubation 
and  safety. 

Preparation  of  the  Operator. — The  nose  and  mouth  should  be  pro- 


390 


THE  AIE  PASSAGES 


tected  with  gauze  and  the  clothing  by  a  sheet  or  gown  so  that  if  the 
child  coughs  the  operator  is  not  endangered. 

Preparation  of  the  Patient. — The  child's  body  should  be  firmly 
wrapped  in  a  strong  sheet  or  blanket  so  that  the  arms  and  legs  are 
secured  sufficiently  to  make  the  inevitable  struggling  ineffectual. 
Thus  secured  the  patient  is  held  upon  the  lap  of  the  nurse  with 
the  head  on  the  nurse's  right  shoulder,  who,  with  her  left  hand, 
securely  holds  the  head  in  position  and  with  her  right  encircles  the 

child's  body.  If  the  child 
struggles  greatly  a  third 
person  may  be  necessary 
to  hold  the  head  in  posi- 
tion, for  this  is  a  very  im- 
portant part  of  the  pro- 
cedure. (Fig.  135.) 

Preparation  of  the  In- 
struments (Fig.  136).— 
A  well-oiled  silk  thread 
is  loosely  looped  through 
the  eye  of  the  tube  so  that 
withdrawal  of  the  tube 
can  be  readily  accom- 
plished if  it  is  misplaced 
or  is  coughed  into  the 
pharynx,  or  the  thread 
can  be  easily  withdrawn 
when  the  tube  is  properly 
placed.  The  rest  of  the  instruments  should  be  conveniently  placed 
for  rapid  work  and  all  previously  sterilized.  The  introducer  must 
be  fitted  with  a  proper  sized  tube. 

The  Operation. — The  first  step  is  to  introduce  the  gag,  and  suffi- 
cient time  should  be  taken  to  have  it  properly  placed  so  that  it 
will  remain  in  position  and  not  obstruct  the  field  of  operation  by 
slipping  or  turning,  as  is  often  the  case.  After  the  gag  is  placed 
the  assistant  throws  the  child's  head  slightly  backward  while  at  the 
same  time  making  slight  but  persistent  traction  and  supporting  the 


FIG.  135. — POSITION  OF  CHILD  FOR  INTUBATION. 


INTUBATION 


391 


gag.  The  introducer  having  been  previously  armed  with  tho  proper 
tube  is  held  in  the  right  hand  of  the  operator,  while  the  glottis  is 
located  with  the  forefinger  of  his  left,  and  using  that  as  his  guide, 
he  passes  the  tip  of  the  tube  directly  into  the  larynx.  This  is  done 
by  keeping  strictly  to  the  median  line  and  keeping  the  handle  paral- 
lel with  the  chest  until  the  tip  of  the  tube  is  well  back  toward  the 
pharynx,  when  a  curved  motion  through  the  elevation  of  the  handle 


FIG.  136. — INSTRUMENTS  USED  IN  INTUBATION.  (Fowler.) 

carries  the  tip  of  the  tube  to  the  larynx.  When  certain  that  the 
tube  is  in  place  the  thumb  of  the  right  hand  releases  the  tube  from 
the  obturator  and  the  finger  of  the  left  hand  adjusts  it  more  per- 
fectly in  place.  Both  fingers  should  aid  in  accomplishing  this  ad- 
justment, because  when  reliance  is  placed  alone  upon  the  finger  that 
holds  the  introducer  the  tube  may  stick  and  be  dislodged.  (Fig. 
137.)  After  the  withdrawal  of  the  introducer  if  the  breathing 
shows  improvement  the  gag  is  removed.  After  from  fifteen  to 


392 


THE  AIR  PASSAGES 


twenty  minutes,  if  everything  is  all  right,  the  thread  may  be  cut 
and  withdrawn.  However,  if  a  very  competent  nurse  is  not  avail- 
able, this  should  be  left  in  place  and  fastened  to  the  cheek  with 
tape  while  the  child's  arms  are  restrained  so  that  it  cannot  interfere 
with  the  thread.  In  this  way  instant  removal  of  the  tube  is  easily 
accomplished.  Every  step  of  the  procedure  should  be  carried  on 
with  the  greatest  gentleness  compatible  with  rapidity  and  certainty. 
After-treatment. — An  experienced  attendant  is  necessary  at  all 
times  to  guard  against  accidental  clogging  of  the  tube  or  its  dis- 
lodgment.  By  lowering  the  head,  liquid  nourishment  may  be 
freely  given  without  fear  of  interfering  with  the  tube.  In  some 
instances  we  have  found  it  more  desirable  to  introduce  a  stomach 


A  B 

FIG.  137. — A.  METHOD  OF  DRAWING  THE  EPIGLOTTIS  FORWARD.  B.  INTRODUCING  TUBE 
ALONG  SIDE  OF  FINGER.  C.  PUSHING  THE  TUBE  INTO  POSITION  WITH  INDEX  FINGER. 
(Morrow.) 

tube   and   administer   nourishment  in  that  way  or  by   a   catheter 
through  the  nose. 

Removal  of  the  Tube. — This  demands  the  same  amount  of  prep- 
aration as  the  introduction  and  is  accomplished  as  soon  as  the 
symptoms  allow,  which  is  usually  on  the  third,  fourth,  or  the  fifth 
day.  With  the  child  in  the  same  position  as  at  introduction  the 
gag  is  placed  as  before  and  the  extractor  passed  down  into  the  lumen, 
where  its  blades  are  separated  and  the  tube  withdrawn.  It  is  neces- 
sary to  perform  this  rapidly  also. 

TRACHEOTOMY 

Since  the  introduction  of  antitoxin  in  the  treatment  of  diphtheria 
and  the  use  of  O'Duryer's  method  of  intubation  for  laryngeal  ob- 
struction tracheotomy  has  a  much  more  limited  field.  It  is  still 


TRACHEOTOMY  393 

indicated  however,  when  intubation  fails  to  relieve,  as  an  emergency 
measure  when  foreign  bodies  obstruct  the  air  passages,  and  as  a 
preliminary  procedure  to  other  operations. 

Anatomical  Points. — (a)  Tracheotomy  is  high  or  low  as  it  is 
performed  above  or  below  the  isthmus  of  the  thyroid.  In  children 
the  high  operation  is  always  chosen. 

(b)  The  difficulties  of  tracheotomy  increase  the  nearer  the  in- 
cision is  made  to  the  sternal  notch,  just  as  the  depth  of  the  trachea 
increases,  and  the  number  and  importance  of  the  overlying  struc- 
tures. 

(e)  The  patient's  shoulders  should  be  raised  by  a  sand  bag  and 
the  head  thrown  back  and  steadied.  This  position  draws  the  trachea 
up  and  throws  it  forward,  thereby  increasing  the  operative  field  and 
bringing  the  trachea  nearer  the  surface. 

(d)  The  incision  should  be  made  exactly  in  the  median  line. 
This  line  corresponds  to  the  point  where  the  layers  of  fascia  meet 
and  to  the  median  raphe  between  the  muscles,  and  incurs  the  least 
amount  of  hemorrhage  by  avoiding  the  greatest  number  of  vessels. 
The  exact  median  incision  is  also  the  best  preliminary  precaution 
against  losing  the  trachea  by  getting  off  to  one  side. 

(e)  The  trachea  has  a  considerable  range  of  mobility;  it  rises 
and  falls  with  each  respiration.     It  should  therefore  be  steadied  by 
transfixing  it  with  a   sharp  hook  and  drawing  it  forward   before 
opening  it. 

(f )  The  trachea  should  be  opened  by  a  short  thrust  of  the  knife 
in  order  to  penetrate  the  lining  mucous  membrane.     The  mistake 
has  been  made  of  pushing  the  mucosa  in  front  of  the  knife  and 
introducing  the  tube  between  the  mucous  membrane  and  the  fibro- 
cartilaginous  portion  of  the  trachea. 

(g)  In  children  the  difficulties  of  tracheotomy  are  increased  by 
its  smaller  size  and  greater  depth.      The  presence  of  the   thymus 
gland  and  the  higher  level  of  the  vessels  at  the  root  of  the  neck 
must  be  taken  into  consideration. 

(h)  The  greatest  danger  in  tracheotomy  is  hemorrhage  getting 
into  trachea  and  causing  asphyxiation  by  obstructing  the  bronchi: 
therefore,  hemostasis  should  be  complete  before  opening  the  trachea. 


394 


THE  AIE  PASSAGES 


Operation. — The  operation  consists  in  incising  the  trachea  and 
introducing  through  the  opening  a  cannula,  through  which  air  reaches 
the  lungs. 

Instruments. — When  instant  operation  is  necessary  a  knife  and 
a  rubber  tube  may  be  the  means  of  saving  life.  When  deliberation 
is  possible  provide  a  knife,  scissors,  thumb-forceps,  hemostatic  for- 
ceps, retractors,  tenacula,  and  a  tracheotomy  tube. 

Anesthesia. — While  in  extreme  cases  a  rapid  operation  may  be 
done  without  anesthesia,  it  is  better  when  practical  to  give  light 


FIG.  138. — A.  OUTER  TUBE  OF  TRACHEAL  CANNULA.  B.  INNER  TUBE  OF  TRACHEAL 

CANNULA. 

chloroform  anesthesia  to  children,  since  their  struggles  embarrass 
the  operator. 

Envelop  the  patient's  body  in  a  blanket  with  the  arms  extended 
and  held  close  to  the  body.  Place  the  patient  on  a  table  in  a  good 
light,  the  shoulders  elevated,  and  the  head  thrown  back,  so  that  the 
neck  is  extended  and  the  trachea  thrown  forward. 

An  assistant  steadies  the  patient's  head,  while  another  at  the 
foot  of  the  table  keeps  the  extremities  in  full  extension.  Steady 
the  trachea  by  grasping  the  larynx  with  the  thumb  and  middle 
finger  of  the  left  hand,  the  index  finger  being  placed  on  the  cricoid 
cartilage.  Make  an  incision  of  about  an  inch  from  the  cricoid 


TRACHEOTOMY 


395 


cartilage  downward,  and  exactly  in  the  median  line.  Divide  the 
soft  parts  down  to  the  trachea,  ligate  all  bleeding  points,  and  retract 
the  wound  edges  so  as  to  expose  the  trachea. 

Firmly  fix  the  trachea  with  tenacula,  draw  it  forward,  and  open 
the  trachea  by  a  short  thrust  of  the  knife  so  that  the  mucous  lining 
is  penetrated  as  well  as  the  fibrocartilaginous  tube.  Introduce  two 
silk  retraction  sutures  in  the  edges  of  the  tra- 
cheal  wound  so  that  the  slit  may  be  held  apart 
(the  silk  retraction  sutures  should  be  perma- 
nently retained  in  case  the  tube  needs  to  be  re- 
inserted), with  the  tracheal  wound  held  apart 
by  the  retraction  sutures  pass  the  outer  tube 
(Fig.  138 A)  backward  and  downward  into  the 
trachea  and  then  immediately  insert  the  inner 
cannula.  (Fig.  138  B.)  Secure  the  tube  in 
place  by  the  attached  tapes  tied  behind  the  neck. 

In  emergency  cases,  when  a  metallic  tube 
is  not  at  hand,  an  improvised  rubber  tube  may 
be  employed  as  shown  in  Fig.  139. 

After-treatment. — Protect  the  opening  of  the 
tube  with  a  few  layers  of  moist  gauze.  A 
trained  nurse  should  be  in  constant  attendance 
to  remove  and  cleanse  the  inner  tube  if  obstruc- 
tion occurs,  otherwise  the  inner  tube  should  be 
removed,  cleansed  and  boiled  morning  and 
night.  The  tube  should  be  worn  only  as  long  as 

normal  respiration  is  impeded.  Normal  respiration  may  be  tested 
by  closing  the  tracheal  opening  with  the  finger.  At  first  the  tube 
may  be  removed  for  a  few  hours  at  a  time;  after  the  child  has 
gradually  become  accustomed  to  normal  respiration  the  tube  is  dis- 
pensed with. 


FIG.  139. — IMPROVISED 
TRACHEAL  CANNULA 
MADE  FROM  RUBBER 
TUBING.  (Brewer.) 


396  THE  NECK 

CHAPTER  XLIX 

THE    NECK 

CONGENITAL  TORTICOLLIS 

Congenital  torticollis  (wry-neck)  refers  to  the  special  attitude 
which  the  head  and  neck  assume  due  to  unilateral  myogenic  con- 
tractures  usually  affecting  the  sternomastoid  and  scalenus  anticus 
muscles. 

Etiology. — The  etiology  of  this  affection  may  be  found  as  in 
other  developmental  defects  (such  as  hare-lip,  etc.)  to  be  the  result 
of  intrauterine  forces,  which  manifest  themselves  either  in  incom- 
plete or  in  abnormal  development;  or  it  may  be  the  result  of  ob- 
structive traumatism  in  which  is  inaugurated  a  chronic  interstitial 
myositis  with  subsequent  contractures.  Congenital  wry-neck  must 
not  be  confounded  with  postural  wry-neck  secondary  to  other 
pathological  conditions,  such  as  cervical  spinal  caries,  suppurative 
cervical  adenitis  about  the  sternomastoid,  otitis  with  glandular 
swelling,  ocular  defects,  etc. 

Pathology. — Certain  pathological  changes  occur  which  have  an 
important  bearing  on  the  treatment.  While  the  sternomastoid 
muscle  is  most  prominently  affected,  it  must  not  be  forgotten  that 
the  scalenus  anticus  is  also  involved.  Thus  the  muscles  undergoing 
fibrous  degeneration  contract,  shorten,  and  pull  the  head  toward  the 
corresponding  shoulder.  The  position  of  the  sternomastoid  muscle 
is  such  that  it  forms  a  prominent  cord  which  is  increased  when 
the  head  is  forced  into  normal  position.  It  is  also  to  be  recalled 
that  the  two  heads  of  the  sternomastoid — the  sternal  and  clavicular 
— confer  upon  this  muscle  a  double  function — they  pull  the  head 
toward  the  shoulder,  and  rotate  it  toward  the  opposite  side. 

Hence  the  deformity  will  vary  somewhat  according  to  which 
head  is  affected.  If  the  contraction  is  chiefly  in  the  sternal  head, 
rotation  will  predominate;  if  in  the  clavicular  head,  inclination  will 
be  most  marked. 

As  a  result  of  this  disturbed  muscular  balance  there  are  pro- 


CONGENITAL    TORTICOLLIS 


397 


nounced  secondary  changes  shown  in  an  asymmetry  of  the  head  and 
face.  The  changed  static  conditions  of  the  affected  side  interfere 
with  nutrition,  retard  development,  and  result  in  craniofacial 
atrophy.  Again,  this  facial  scoliosis  changes  the  horizontal  plane 
of  the  eyes,  ears,  nose,  and  mouth,  into  one  of  obliquity.  The  shoul- 
der girdle  of  the  affected  side  is  drawn  up,  and  there  follows  a 
cervical  scoliosis  with  the  curvature  directed  toward  the  sound  side, 
with  secondary  compensatory  curves  in  the  dorsal  and  lumbar 
regions  as  the  structure  and  function  of  the  spinal  column  demand. 

Symptoms. — The  typical  deformity  due  to  the  two-fold  function 
of  the  sternomastoid  muscle  is 
easily  recognized.  The  head  is 
inclined  toward  the  affected  side 
and  rotated  toward  the  sound 
side  (Fig.  140).  The  malposi- 
tion of  the  head  is  so  fixed  that 
it  may  be  increased  but  not  di- 
minished. All  other  changes 
are  caused  secondarily,  and  are 
adaptation  changes  of  growth. 
The  two  cardinal  symptoms — 
inclination  and  rotation — will 
vary  in  severity  according  as 
the  sternal  or  clavicular  heads 
of  the  muscle  are  most  affected. 

Asymmetry  of  the  face  and  curvatures  of  the  spine  have  already 
been  noted  in  the  pathology. 

Diagnosis. — There  should  be  little  difficulty  in  recognizing  true 
wry-neck  by  the  hard  and  tense  contracture  of  the  degenerated  and 
shortened  muscle.  We  must  differentiate  postural  wry-neck  result- 
ing from  other  pathological  conditions  which  is  temporarily  a  posi- 
tion of  greatest  comfort.  Thus  cervical  caries,  subluxations, 
adenitis,  etc.,  must  be  eliminated  by  careful  examinations  of  the 
vertebras  in  the  neck  and  through  the  mouth  cavity;  by  the  use 
of  the  X-ray ;  by  the  von  Pirquet  test ;  by  the  absence  of  acute  in- 
flammatory symptoms, 


FIG.  140. — TORTICOLLIS.     NOTE  THE  INCLINA- 
TION AND  ROTATION  OF  THE  HEAD.  (Estor.) 


398 


THE  NECK 


Treatment. — The  operative  treatment  of  congenital  wry-neck  is 
always  to  be  preferred  since  it  removes  at  once  the  obstacle  to  re- 
duction. The  operation  should  consist  of  an  open  resection  of  the 
muscle  with  adequate  exposure  of  the  parts.  Subcutaneous  tenot- 
omies  in  the  presence  of  asepsis  are  no  longer  admissible;  in  this 
region,  with  its  important  vessels,  surgery  in  the  dark  is  inex- 
cusable. 

An  adequate  horizontal  incision  should  be  made  a  finger's 
breadth  above  the  clavicle;  avoid  if  possible  the  external  jugular 

vein,  which  lies  close  to  the  pos- 
terior margin  of  the  muscle; 
isolate  the  muscle  and  divide 
both  heads  on  a  grooved  di- 
rector. Be  sure  that  the  muscle 
fibers  are  completely  divided  as 
well  as  the  fascia.  If  necessary 
the  scalenus  anticus  may  be  re- 
sected and  an  extirpation  of  scar 
tissue  be  done  in  addition. 
When  the  contraction  is  extreme 
a  plastic  operation  will  increase 
the  length  of  the  muscle  by  di- 
viding the  clavicular  portion 
near  the  clavicle  and  the  sternal 
portion  near  the  bifurcation  and 
uniting  the  two  heads  (Fig. 

141): 

After  the  resection  is  com- 
pleted the  wound  is  closed  without  drainage  and  the  head  and  neck 
dressed  with  plaster  bandages  in  an  over-corrected  position  and 
retained  in  this  position  for  several  weeks.  The  results  of  opera- 
tion are  always  more  favorable  in  the  early  cases — secondary  cur- 
vatures of  the  spine  form  an  unpleasant  complication.  The  parents 
should  be  informed  that  while  operation  will  correct  the  position  of 
the  head  the  facial  asymmetry  will  remain  unaltered. 

If  these  cases  are  seen  very  early,  in  the  first  weeks,  treatment 


FIG.  141. — LINES  OF  INCISION  FOR  PLASTIC 
OPERATION  ON  THE  STERNOMASTOID 
MUSCLE.  AB  and  CD  are  united  by 
suture. 


TUBERCULOUS  GLANDS  OF  THE  NECK     300 

should  begin  by  correcting  the  position  with  pillows  placed  under 
the  affected  side.  If  there  is  hematoma  of  the  muscle  it  should  be 
massaged  and  the  surface  painted  with  iodin  (half  strength).  When 
the  symptoms  become  more  pronounced  after  the  first  few  months, 
in  spite  of  positional  treatment,  operation  should  be  advised  at  once 
before  secondary  changes  appear. 

Spasmodic  wry-neck  is  very  rare  in  children.  It  may  be  relieved 
by  over-correction  with  plaster  collar,  or  by  division  of  the  spinal 
accessory  nerve. 


TUBEECULOUS  GLANDS  OF  THE  NECK 

Tuberculous  glands  of  the  neck  is  one  of  the  most  common 
affections  of  childhood.  It  will  be  recalled  that  the  neck  is  one  of 
the  most  important  lymph  stations  of  the  body.  Not  only  is  it  rich 
in  lymphatic  glands,  but  these  glands  stand  guard  over  more  gate- 
ways of  infection  than  those  in  any  other  region  of  the  body.  The 
cervical  lymph  glands  drain  not  only  the  regions  in  which  they  are 
situated,  but  also  the  head,  face,  nose,  mouth,  and  throat. 

Again,  the  importance  of  the  lymphatic  system  in  the  child  and 
the  predilection  of  the  tubercle  bacilli  for  lymphatic  tissue  explain 
the  frequency  of  this  affection. 

Anatomical  Considerations. — Anatomically  the  glands  are  ar- 
ranged in  a  glandular  collar  which  encircles  the  neck  at  its  junc- 
tion with  the  head.  From  this  passes  on  either  side  a  vertical 
chain  underneath  the  sternomastoid,  accompanying  the  vessels  and 
nerves  as  far  as  the  junction  of  the  neck  and  thorax. 

Method  of  Invasion. — The  infecting  organism  emigrates  from  the 
mucous  linings  of  the  mouth,  nose,  pharynx,  etc.,  to  the  neighbor- 
ing lymph  spaces  and  are  finally  lodged  in  the  filter  stations  of 
the  lymph  apparatus — the  glands,  which  become  the  centers  of  in- 
flammatory reaction.  Hence,  the  gland  enlarges,  there  is  the  forma- 
tion of  typical  tubercle,  the  inner  structures  break  down,  and  the 
gland  is  converted  into  an  abscess  inclosed  in  the  denser  gland 
capsule,  which  in  turn  breaks  down  and  the  pus  slowly  pushes  its 


400 


THE    NECK 


way  to  the  surface,  discharges,  and  leaves  fistulous  tracts.  In  some 
cases  the  cheesy  glands  remain  encapsulated,  become  calcined,  but 
harbor  for  a  long  time  the  infectious  material. 

Thus  it  will  be  noted  that  the  tuberculous  process  in  the  lymph 
glands  present  the  same  typical  picture  in  the  formation  of  granu- 
lation tissue,  followed  by  caseation,  suppuration,  and  fistulization, 
as  in  other  tissues. 

Symptoms. — While  tuberculous  adenitis  is  extremely  common  in 
childhood  it  is  most  frequently  observed  after  the  fifth  year.  The 

child  is  usually  in  fair  health 
and  is  brought  to  the  physician 
because  the  parents  have  noticed 
a  painless  "lump"  in  the  neck. 
This  "lump"  may  be  a  simple 
enlarged  gland,  which  rolls 
freely  under  the  skin,  or  it  may 
be  formed  of  several  glands  mak- 
ing a  considerable  mass.  These 
enlarged  glands  are  found  in 
typical  locations  corresponding 
to  the  typical  "arrangement  of  the 
lymph  glands — such  as  in  the 
submaxillary  space,  along  the  in- 
ner border  of  the  sternomastoid, 
in  the  carotid  region,  etc.  (Fig- 
142.)  It  is  obvious  that  the 
character  of  the  infected  gland 
differs  according  to  the  grade  of  the  disease. 

Thus,  the  gland  may  be  simply  Jiypertrophied.  The  child  then 
presents  a  fair  condition  of  health.  One  or  more  enlarged  glands 
are  observed  in  front  of  the  sternomastoid,  varying  in  size  from  a 
pea  to  an  egg.  The  glands  are  painless,  hard,  distinctly  separated. 
They  increase  or  diminish  in  volume,  but  never  completely  disap- 
pear. They  are  accompanied  by  no  functional  symptoms  and  the 
parents  are  concerned  only  about  the  deformity  they  present.  At 
a  later  stage  the  glands  may  soften,  become  adherent  to  each  other 


FIG.    142. — BILATERAL    TUBERCULOUS 
GLANDS  OF  THE  NECK. 


TUBERCULOUS  GLANDS  OF  THE  NECK     401 

and  surrounding  structures  as  the  result  of  a  periadenitis,  and  pre- 
sent symptoms  of  fluctuation. 

Finally,  the  overlying  skin  becomes  adherent,  ulcerates,  and 
permits  the  escape  of  the  caseous  pus,  which  leaves  a  fistulous  tract 
communicating  with  the  indurated  mass. 

The  clinical  evolution  from  a  simple  hypertrophy  to  fistuliza- 
tion  may  be  present  in  its  various  stages  in  the  same  subject.  Thus 
it  is  not  uncommon  to  note  in  certain  patients  evidences  of  simple 
hypertrophy  associated  with  glands  in  the  process  of  softening,  and 
those  that  have  already  discharged  their  caseous  contents.  The  clin- 
ical picture  presents  the  different  aspects  of  the  same  disease. 

Again,  a  simple  glandular  hypertrophy  may  be  absorbed  and 
disappear,  or  it  may  become  sclerosed  and  persist  indefinitely  with 
the  same  volume  and  consistency,  presenting  no  symptoms  save  that 
of  deformity. 

Occasionally,  a  superadded  pyogenic  infection  may  change  the 
chronic  character  of  the  disease  into  an  acute  process  characterized 
by  pain,  fever,  and  the  formation  of  an  acute  adenophlegmon. 

Diagnosis. — The  diagnosis  of  tuberculous  glands  of  the  neck  is 
generally  extremely  easy.  Remember  that  tuberculous  glands  are 
by  far  the  most  common  tumor  of  the  neck,  and  the  most  frequent 
cause  of  abscess.  Again,  note  their  chronic  course  and  their  tend- 
ency to  softening  and  pus  formation.  Fortify  the  diagnosis  by 
correlating  the  primary  focus  usually  found  in  a  pharyngeal  tonsil 
(adenoids),  enlarged  tonsils,  chronic  otitis  media,  dental  earies,  etc. 
These  are  the  most  frequent  gateways  of  infection. 

Tuberculous  glands  of  the  neck  must  be  differentiated  from 
lymphosarcoma  by  their  chronic  course  and  the  mobility  and  larger 
range  of  motion  of  the  glandular  masses.  Sarcoma  spreads  through 
the  capsule,  infiltrates  the  surrounding  tissues,  and  forms  a  com- 
pact mass. 

From  true  leukemia  the  disease  must  be  differentiated  by  the 
blood  examination.  In  the  former  there  is  a  marked  leukocytosis. 

From  pseudoleukemia,  or  HodgJcins  disease,  by  the  less  marked 
enlargement  of  the  lymph  nodes.  A  steady  increase  in  the  size  of 
the  tumors,  the  sudden  successive  involvement  of  group  after  group 

LlliK.-^ 
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402  THE  NECK 

of   glands,   and   the   appearance   of   similar   enlargements    in   other 
regions  speak  for  pseudoleukemia  (Johnson). 

From  branchial  cyst  the  disease  is  differentiated  by  the  fact  that 
the  cyst  presents  a  solitary  tumor,  rather  elongated  in  form,  and 
not  accompanied  by  other  small  nodules.  A  small  puncture  will 
eliminate  all  doubt. 

As  a  last  resort  the  diagnosis  may  be  settled  by  excising  a  gland 
and  examining  a  section  macroscopically  and  microscopically,  or 
guinea  pigs  may  be  inoculated  with  the  gland  detritus. 

Treatment. — As  in  all  tuberculous  lesions  the  treatment  should  be 
directed  toward  improving  the  tissues  so  that  the  tubercle  bacilli 
will  cease  to  thrive.  This  will  be  accomplished  by  proper  nutrition, 
unlimited  sunshine,  and  fresh  air.  Local  disinfection  of  the  mouth, 
teeth,  nose,  and  pharynx  should  not  be  neglected. 

Under  proper  hygienic  treatment  many  cases  of  early  tubercu- 
lous adenitis  will  recede  and  operation  may  be  avoided.  The  local 
application  of  iodin  or  other  medicaments  is  the  merest  folly,  since 
it  in  no  way  influences  the  course  of  the  disease.  If  the  gland  is 
softening  and  suppuration  is  present,  a  small  incision  should  be 
made  under  strict  antiseptic  precautions,  the  contents  evacuated,  and 
a  small  rubber  tissue  drain  inserted.  No  curetting  should  be  done, 
since  it  only  opens  the  way  for  new  infection,  and  the  less  the  inter- 
ference the  more  rapid  the  healing. 

When  persistent  and  large  glandular  masses  are  present  OPERA- 
TIVE TREATMENT  is  indicated.  Experience  has  shown  that  the 
radical  removal  of  tuberculous  glands  of  the  neck  is  one  of  the 
most  satisfactory  operations  in  surgery.  Not  only  does  it  prevent 
suppurating  sinuses  and  unsightly  scars,  but  it  relieves  the  region 
at  once  of  the  diseased  tissues.  The  operation  for  the  extirpation 
of  tuberculous  glands  is  formidable:  it  requires  an  exact  anatomic 
dissection,  and  is  a  procedure  of  major  importance. 

Remember  that  if  the  operation  is  attempted  the  removal  of 
the  glands  must  be  radical ;  a  partial  removal  of  the  larger  lymph 
nodes  is  useless  and  is  followed  by  immediate  recurrence.  Again, 
the  palpable  enlargement  is  no  index  of  the  extent  of  involvement: 
one  or  two  enlarged  glands  on  the  surface  usually  indicate  a  nest  of 


BEANCHIAL    FISTULA 


403 


tuberculous  glands  extending  along  the  internal  jugular  vein  even 
as  far  as  the  clavicle.  Therefore,  extensive  incisions,  thorough 
exposure  of  the  parts,  extirpation  of  the  entire  glandular  chain 
whether  enlarged  or  not  are  the  prime  requisites  of  this  operative 
procedure. 

No  description  of  the  details  of  the  operation  is  possible.  Only 
a  resourceful  and  experienced  surgeon  should  attempt  it.  It  is  sug- 
gested that  the  lines  of 
incision  be  so  planned 
as  to  give  the  greatest 
exposure  with  the  least 
resulting  scar.  (Fig. 
143.)  Horizontal  inci- 
sions in  the  natural 
folds  of  the  neck;  the 
only  vertical  incision  be- 
ing placed  behind  the 
sternomastoid ;  skin  su- 
tures of  horse-hair  with 
fine  needle  give  the 
best  cosmetic  results. 
Though  the  operative 
technique  is  difficult 
and  the  procedure  is  a 
long  one,  it  is  remarkable  how  speedy  the  recovery  and  how  satis- 
factory the  results.  These  patients  are  usually  out  of  bed  the  day 
after  the  operation  and  healing  is  cogj^iete  in  a  week. 


FIG.  143. — LINE  OF  INCISION  FOB  THE  RADICAL 
REMOVAL  OF  TUBERCULOUS  GLANDS  OF  THE 
NECK. 


II 


BRANCHIAL   FISTULJE 

Branchial  fistula  are  either  primary,  due  to  the  imperfect 
obliteration  of  one  of  the  branchial  clefts  and  exist  at  birth,  or  are 
secondary  to  the  opening  of  a  branchial  cyst.  The  median  fistulse 
are  quite  rare  and  are  concerned  with  the  imperfect  obliteration 
of  the  thyroglossal  duct.  The  lateral  fistulas  are  more  frequent; 


404 


THE  NECK 


sometimes  unilateral,  sometimes  bilateral  and  symmetrical.  The 
external  orifices  of  these  fistulse  are  usually  indicated  by  a  nodule 
of  skin  and  are  situated  along  the  line  of  the  anterior  border  of  the 
sternomastoid  muscle  opposite  the  angle  of  the  jaw,  the  thyrohyoid 
space,  and  the  sternoclavicular  articulation  (Fig.  144).  The  in- 
ternal orifices  are  either  in  the  region  of  the  tonsil  or  the  sinus 
pyriformis. 

Clinical  Characteristics. — There  is  a  more  or  less  constant  flow 
of  secretion  from  the  fistula  which  is  increased  by  the  movements 
of  mastication  and  deglutition.  The  fistula  may  temporarily  close, 
become  inflamed,  and  give  rise  to  an  abscess,  which  subsequently  dis- 
charges. When  a  probe  is  intro- 
duced into  the  canal  it  cannot 
penetrate  for  more  than  two  or 
three  centimeters  without  incit- 
ing a  spasmodic  cough  or  a  pain- 
ful irritation  of  the  pharynx. 
The  fistula  is  complete  when  it 
has  a  pharyngeal  orifice,  which 
is  usually  situated  in  the  vicinity 
of  the  tonsils.  The  course  of 
these  fistula?  is  fairly  uniform: 
— along  the  anterior  or  inferior 
surface  of  the  sternomastoid  to 
the  greater  cornu  of  the  hyoid 
bone,  it  then  curves  in  and  passes 
under  the  posterior  belly  of  the 
digastric  muscle  to  its  orifice  in 
the  pharynx. 

The  fistula  is  incomplete  if  it  has  only  an  external  opening  in 
the  skin,  or  only  an  internal  opening  near  the  tonsil ;  the  latter  are 
rarely  recognized,  but  their  presence  may  be  suspected  if  by  pressure 
on  the  side  of  the  neck  there  is  a  gush  of  serous  fluid  from  a  peri- 
tonsillar  orifice. 

It  is  difficult  to  demonstrate  the  course  of  one  of  these  fistulse 
since  palpation  gives  no  clew,  because  of  the  thickness  of  the  over- 


FIG.    144. — LOCATION   OF   THE    ORIFICES 
OF  PERSISTENT  BRANCHIAL  FISTULA. 


BRANCHIAL    FIBRO-CHONDROMATA  405 

lying  structures.  An  injection  of  bismuth  emulsion  into  the  fistu- 
lous  track  will  appear  on  a  radiograph  and  be  of  some  assistance  in 
the  subsequent  treatment. 

Treatment. — Total  extirpation  is  the  treatment  of  choice.  Unless 
the  tract  is  completely  removed,  a  return  of  the  fistula  is  to  be  ex- 
pected. It  is  obvious  that  this  operation  involves  a  careful  dissec- 
tion and  exact  anatomical  knowledge  especially  in  dealing  with  that 
part  of  the  tract  that  penetrates  deeply  into  the  pharyngeal  region 
and  is  in  close  proximity  to  the  carotid  vessels.  Hence  each  case 
should  be  carefully  considered.  If  the  fistula  is  not  very  apparent 
and  is  secreting  only  a  few  drops  at  infrequent  intervals  it  may 
be  well  to  try  injections  of  tincture  of  iodin,  especially  in  a  girl 
where  a  scar  is  to  be  avoided. 

The  injection  treatment  is  sometimes  successful.  If,  however, 
the  fistula  is  quite  apparent,  with  a  tendency  to  become  inflamed 
and  suppurate,  we  should  not  hesitate  to  propose  total  extirpation. 


BRANCHIAL   FIBRO-CHONDROMATA 

There  are  small,  hard  appendages  sometimes  found  on  the  face 
or  neck  of  the  new-born,  which  are  the  result  of  the  proliferation 
of  histological  elements  along  the  course  of  the  branchial  clefts. 
They  form  small,  hard  tumors,  more  or  less  pedunculated,  and 
covered  by  adherent  skin.  They  are  found  along  the  line  of  the 
intermaxillary  cleft,  especially  in  the  neighborhood  of  the  ear,  or 
along  the  anterior  border  of  the  sternomastoid. 

As  a  rule  they  are  quite  small,  painless,  and  composed  of  fibro- 
cartilaginous  tissue.  Their  removal  is  demanded  only  because  of 
the  deformity  which  they  occasion. 

Treatment. — When  the  pedicle  is  very  narrow  a  simple  ligation 
and  excision  are  sufficient;  when  the  pedicle  is  broad,  a  curved  in- 
cision at  the  base,  with  suture  of  the  skin  opening,  is  necessary.  In 
certain  cases  the  cartilaginous  elements  extend  deeply  into  the  at- 
tached base  of  the  tumor  and  unless  completely  extirpated  the 
tumor  may  return. 


406 


THE  NECK 


CONGENITAL    CYSTS    OF    THE    NECK 

Lymphatic  Cysts  (Hydrocele  of  the  Neck}. — The  lymphatic  cysts 
are  large  congenital  tumors  which  may  attain  enormous  proportions, 
situated  in  the  lateral  surface  of  the  neck,  and  often  extending  from 
the  lower  jaw  to  the  clavicle.  (Sometimes  under  the  clavicle  into 
the  axilla.)  The  pathology  of  these  cysts  is  obscure;  the  present 
theory  places  their  origin  in  the  lymphatic  system. 

They   are  generally  multilocular   and   consist   of   a  number   of 

cysts  of  varying  size.  The  content 
of  the  cysts  varies;  at  times  it  is 
a  clear  transparent  serum,  again 
it  may  be  mixed  with  blood  or 
even  seropurulent. 

SYMPTOMS. — Clinically  these 
cysts  present  a  tumor  of  variable 
volume,  usually  quite  large,  situ- 
ated on  the  side  of  the  neck,  which 
it  markedly  deforms.  The  tumor 
is  either  round  or  lobulated.  The 
overlying  skin  presents  a  normal 
appearance  and  is  independent  of 
the  tumor.  (Fig.  145.)  When 
the  cyst  is  multilocular,  its  con- 
sistency is  soft  and  flabby,  like  that  of  a  varicocele ;  or,  when  a  cyst 
cavity  predominates,  it  may  be  fluctuating. 

The  functional  symptoms  are  ordinarily  of  little  importance. 
In  spite  of  their  volume  they  rarely  give  any  trouble  beyond  the 
inconvenience  and  deformity.  Exceptionally,  when  these  cysts  in- 
vade the  pharynx  and  trachea,  they  may  interfere  with  respiration 
or  deglutition. 

The  method  of  progression  of  these  cysts  is  characteristic.  They 
extend  like  neoplasms,  gradually  invading  the  muscular  planes,  and 
even  infiltrate  the  muscles  themselves.  They  pass  under  the  clavicle 
into  the  axilla ;  or  behind  the  sternum  and  invade  the  mediastinum. 
They  form  adhesions  to  the  great  vessels. 


FIG.  145. — CONGENITAL  LYMPHATIC 
CYST  OF  THE  NECK.  (Spitzy.) 


CONGENITAL    CYSTS    OF    THE    NECK  407 

DIAGNOSIS. — There  is  no  congenital  tumor  which  presents  the 
clinical  picture  of  a  lymphatic  cyst.  Tuberculous  glands  and  bran- 
chial cysts  are  small  and  develop  later.  A  lipoma  may  be  equally 
voluminous  but  it  is  less  localized,  develops  toward  the  posterior 
surface  of  the  neck,  and  presents  no  point  of  fluctuation. 

An  angioma  may  cause  some  confusion  but  the  absence  of  dis- 
coloration of  the  skin,  the  absence  of  turgescence  of  the  tumor  when 
the  child  cries,  the  lack  of  complete  reductibility  enable  us  to  recog- 
nize the  lymphatic  cyst. 

TREATMENT. — Total  extirpation  may  be  called  ideal,  but  it  is 
possible  only  when  the  cyst  is  small,  well  defined,  and  non-' 
infiltrating.  The  long  and  difficult  dissection  which  some  of  these 
tumors  impose  renders  total  extirpation  inexpedient.  If  the  tumor 
is  increasing  rapidly  we  may  puncture  and  drain,  or  it  may  be  wise 
to  be  content  with  partial  extirpation,  and  marsupialize  the  remain- 
ing portion  by  suturing  the  sac  to  the  edges  of  the  skin  incision. 
A  complete  cure  is  then  obtained  on  condition  that  all  the  partitions 
which  separate  the  cystic  cavities  are  destroyed. 

Branchial  cysts  are  due  to  imperfect  obliteration  of  oner  of  the 
branchial  clefts,  which  may  result  in  a  branchial  fistula  when  the 
entire  tract  remains  open,  there  being  an  internal  and  external 
orifice ;  or  a  cystic  fistula  when  one  end  of  the  tract  is  closed ;  or  a 
branchial  cyst  when  both  ends  of  the  tract  are  closed,  the  inter- 
mediate portion  remaining  open.  It  is  obvious  that  these  cysts  are 
situated  laterally.  But  there  are  also  median  cysts  due  to  the  im- 
perfect obliteration  of  the  thyroglossal  duct,  these  cysts  occupy  a 
median  position  in  front  of  the  trachea  from  the  foramen  cecum 
to  the  thyroid  gland. 

SYMPTOMS. — Clinically  these  cysts  are  either  median  or  lateral. 
They  are  rarely  seen  at  birth,  but  usually  appear  during  the  early 
years  of  life  or  toward  puberty.  They  give  so  little  trouble  that 
the  physician  is  rarely  consulted  until  at  a  more  advanced  age  and 
then  because  of  the  deformity.  The  tumor  is  small,  about  the  size 
of  a  walnut,  rather  elongated,  and  of  hard  consistency.  The  skin 
is  not  adherent,  and  the  tumor  is  movable  in  a  transverse  direction, 
riot  vertically. 


408  THE  NECK 

The  cyst  may  undergo  a  rapid  increase  in  size,  followed  by  in- 
flammation and  suppuration,  and  open  externally,  the  consequence 
of  which  is  a  fistula  which  will  continue  to  discharge  until  it  is 
destroyed.  These  fistulas  may  close  temporarily,  but  in  a  few  weeks 
suppuration  is  reproduced  and  the  fistula  opens  anew.  This  same 
succession  of  phenomena  is  repeated  until  the  fistulous  tract  is 
extirpated. 

TREATMENT. — Complete  extirpation  is  the  only  treatment  which 
will  prevent  their  return.  If  the  cyst  is  completely  walled  off  the 
extirpation  is  simple,  but  usually  the  cyst  is  connected  with  a  very 
small  canal  which  is  directed  toward  the  pharynx  in  the  lateral 
cysts,  and  toward  the  base  of  the  tongue  in  the  median  cysts.  To 
follow  this  canal  to  its  termination  is  extremely  difficult,  and  yet 
if  the  extirpation  is  not  complete  the  fistula  will  later  return. 


DERMOID  CYSTS  OF  THE  NECK 

The  suprahyoid  median  cysts  develop  in  the  floor  of  the  mouth 
between  the  geniohyoglossus  and  hyoglossus  muscles,  and  are  easily 
mistaken  for  ranula.  When  they  attain  considerable  size  they 
project  in  the  floor  of  the  mouth,  elevate  the  tongue,  and  form  a 
prominence  below  the  chin.  They  are  doughy  in  consistence  and 
are  adherent  either  to  the  symphysis  menti  or  to  the  body  of  the 
hyoid.  They  are  painless  and  develop  slowly.  They  may  be  extir- 
pated either  by  the  mouth  or  by  a  submental  incision. 

The  suprahyoid  lateral  cysts  are  situated  at  the  angle  of  the  jaw 
and  form  a  prominence,  when  of  considerable  size,  both  in  the 
pharynx  and  on  the  side  of  the  neck.  They  form  adhesions  with 
the  vessels  of  the  neck  and  for  this  reason  are  difficult  to  extirpate. 


LIPOMAS  OF  THE  FACE  AND  NECK 

Lipomas  must  be  reckoned  among  the  more  frequent  congenital 
tumors.     They  are  either  superficial  or   deep,   and  the  latter  are 


MALFORMATIONS    OF    THE    ESOPHAGUS  409 

often  attached  to  the  periosteum  and  underlying  bone.  Sometimes 
the  lipomas  are  associated  with  angiomas  (angiolipomas)  which  is 
recognized  on  excision  by  their  vascular  arrangement  and  the  char- 
acteristic convoluted  capillaries  between  the  fatty  lobules. 

Congenital  lipomas  of  the  neck  are  characterized  by  their  great 
volume  and  tendency  to  diffuse.  They  extend  between  the  muscles, 
toward  the  supraclavicular  fossa,  the  thorax,  and  axillary  region. 
The  overlying  skin  is  normal,  they  are  of  soft  consistency,  and 
indefinitely  lobulated.  They  are  neither  well  defined,  reducible,  nor 
fluctuating,  which  distinguishes  them  from  cystic  lymphangiomas. 
When  these  tumors  extend  toward  the  pharynx  and  trachea  they 
may  interfere  with  deglutition  and  respiration. 

Their  chief  characteristic  is  their  tendency  to  diffuse.  They  are 
not  well  defined  and  their  extirpation  is  consequently  difficult.  The 
only  treatment  is  excision.  If  the  tumor  is  very  large  it  may  be 
expedient  to  perform  the  extirpation  in  several  stages. 


CHAPTER  L 

THE    ESOPHAGUS 

MALFORMATIONS  OF  THE  ESOPHAGUS 

Varieties. — Malformations  of  the  esophagus  are  extremely  rare. 

COMPLETE  ABSENCE  of  the  esophagus  has  been  reported,  but 
there  are  only  a  few  cases  on  record.  In  these  cases  both  the  upper 
and  cardiac  openings  were  closed  and  between  the  two  there  was  no 
trace  of  an  esophageal  tube. 

PARTIAL  ABSENCE  is  not  quite  so  rare.  The  anomaly  is  variable. 
Sometimes  the  upper  end  extends  for  a  variable  length  only  to  dis- 
appear in  adhesions  to  the  trachea ;  the  lower  end  is  missing. 

ABNORMAL  COMMUNICATIONS. — Abno'rmal  communications  are 
always  into  the  trachea.  The  esophagus  may  be  present  in  its  en- 
tirety and  communicate  to  a  greater  or  less  extent  with  the  trachea. 


410  THE  ESOPHAGUS 

Usually  a  communication  with  the  trachea  is  accompanied  by  par- 
tial absence  of  the  esophagus  (Froelich). 

Symptoms. — The  symptoms  depend  upon  the  character  of  the 
deformity.  It  is  obvious  that  in  absence  of  the  esophagus  every 
swallow  of  food  is  rejected.  When  there  is  a  communication  with 
the-  trachea  every  swallow  of  food  is  followed  by  a  spasm  of  suffo- 
cation and  coughing.  If  all  the  milk  is  not  regurgitated  we  may 
conclude  that  there  is  a  simple  communication  between  the  esoph- 
agus and  trachea,  and  alimentation  may  be  provided  by  means 
of  a  stomach  tube. 

Treatment. — The  only  treatment  of  these  conditions  is  to  do  a 
gastrostomy ;  and  this  operation  on  children  offers  little  hope  of 
success.  Attempts  to  restore  the  missing  portion  of  the  esophagus 
by  means  of  intestinal  grafts  are  purely  experimental. 


CONGENITAL   STENOSIS   OF   THE   ESOPHAGUS 

Congenital  stenosis  of  the  esophagus  is  never  diagnosed  in  the 
infant.  It  is  only  later  when  the  character  of  the  food  is  coarser 
that  difficulty  in  swallowing  is  noticed.  The  passage  of  an  esopha- 
geal  sound  will  indicate  the  location  of  the  stricture,  and  esophagos- 
copy  will  indicate  its  character. 

The  treatment  consists  in  progressive  dilatation,  and  persistent 
treatment  assures  a  cure. 


FOREIGN    BODIES    IN    THE    PHARYNX    AND    ESOPHAGUS 

The  arrest  of  foreign  bodies  in  the  pharynx  and  esophagus  is 
a  frequent  accident  of  childhood.  Buttons,  marbles,  coins,  jack 
stones,  fish  bones,  etc.,  are  caught  at  certain  points  in  the  pharyngo- 
esophageal  tube  and  produce  a  train  of  symptoms  always  distress- 
ing and  sometimes  fatal. 

Anatomical  Peculiarities. — There  are  certain  anatomical  peculiar- 
ities in  the  caliber  of  the  esophagus  which  have  an  important  bear- 


FOREIGN  BODIES  IN  THE  ESOPHAGUS 


411 


S- 


ing  upon  the  impaction  of  foreign  bodies.     It  must  be  remembered 
that  there  are  three  normal  points  of  constriction  (Fig.  140)  : 

A.  At    its    beginning    opposite    the    cricoid    cartilage.       The 
pharynx,  like  a  funnel,  leads  down  to  the  narrow  opening  of  the 
esophagus;   hence  foreign   bodies   are  very   apt  to 

become  impacted  at  this  point. 

B.  At  the  point  where  the  left  bronchus  and 
the   arch  of  the   aorta   cross — at  the  level   of  the 
fourth  dorsal  vertebra. 

C.  At  the  point  where  the  esophagus  passes 
through  the  diaphragm. 

At  these  points  the  caliber  is  a  quarter  of  an 
inch  narrower  than  elsewhere. 

As  a  general  rule  in  children  foreign  bodies 
lodge  in  the  cervical  portion  of  the  esophagus  and 
it  is  only  exceptionally  that  they  are  impacted  fur- 
ther down.  The  point  of  election  is  just  above  the 
cricoid  cartilage  wedged  in  between  the  spine  and 
the  larynx. 

Symptoms. — While  the  symptoms  are  quite  vari- 
able, depending  upon  the  character  of  the  im- 
pacted object,  there  are  in  most  instances  an  im- 
mediate spasmodic  contracture  and  a  secondary  in- 
flammatory swelling  which  fixes  the  object  at  its 
point  of  arrest.  Where  the  foreign  body  is  caught 
at  the  junction  of  the  pharynx  and  esophagus  there 
are  at  first  dyspnea  and  asphyxia  resembling  an 
obstruction  of  the  air  passage. 

Afterwards  as  the  object  settles  in  the  esopha- 
gus there  are  well  localized  pain  and  dysphagia  with  or  without 
regurgitation.  These  symptoms  may  be  mild  at  first,  but  as  inflam- 
mation sets  in  they  become  more  intense.  If  relief  is  not  obtained 
or  if  the  patient  is  subjected  to  ill-advised  and  obsolete  methods  of 
removal,  death  may  supervene  from  traumatic  esophagitis.  Fish 
bones  usually  cause  only  the  symptom  of  pain,  while  coins  may  lodge 
in  the  walls  of  the  esophagus  for  weeks  without  causing  any  dis- 


FIG.  146.— THE 
ESOPHAGEAL 
TUBE  SHOW- 
ING THE  THREE 
POINTS  OF  CON- 
STRICTION. 

A.  Opposite  the 
cricoid  cartilage. 

B.  Where    it    is 
crossed  by  the 
left  bronchus. 

C.  Where  it  pass- 
es through  the 
diaphragm. 


412  THE  ESOPHAGUS 

comfort  in  swallowing.  It  is  well  to  note  that  the  localized  pain 
may  persist  even  after  the  foreign  body  reaches  the  stomach,  so  that 
patients  frequently  affirm  that  they  feel  the  presence  of  the  object 
though  it  is  no  longer  lodged  in  the  esophageal  wall. 

Treatment— The  use  of  the  radiograph  for  purposes  of  diagnosis 
and  the  esophagoscope  for  removing  the  foreign  body  has  relegated 
the  various  extractors  to  the  medical  museum.  No  longer  is  it 
necessary  to  grope  blindly  after  foreign  bodies  in  the  esophagus. 
With  the  use  of  modern  instruments  of  precision  the  removal  is 
generally  successful,  and  operation  (esophagotomy)  is  seldom  re- 
quired. The  instruments,  technique,  and  skill  necessary  for  esoph- 
agoscopy  limit  its  practice  to  those  who  are  qualified  by  ex- 
perience for  this  special  line  of  work. 


CICATRICIAL   STENOSIS    OF   THE   ESOPHAGUS 

Cicatricial  stenosis  of  the  esophagus  is  quite  frequent  in  chil- 
dren and  is  produced  by  swallowing  caustic  fluids. 

Clinical  Course. — The  clinical  course  of  these  burns  of  the  esoph- 
agus is  quite  characteristic.  It  is  worthy  of  note  that  immedi- 
ately after  swallowing  the  caustic  the  burns  of  the  lips,  mouth,  and 
pharynx  may  be  quite  insignificant,  and  yet  the  middle  and  lower 
portion  of  the  esophagus  may  be  profoundly  affected.  The  longer 
contact  with  the  esophageal  tube  has  produced  more  tissue  damage; 
hence  the  superficial  damage  to  the  tissues  of  the  mouth  is  no 
guarantee  of  a  benign  prognosis. 

After  the  accident  the  child  at  first  refuses  to  swallow  liquids, 
but  when  compelled  to  do  so  'by  thirst  the  fluid  is  immediately  re- 
gurgitated owing  to  spasm  of  the  esophagus  as  the  fluid  comes  in 
contact  with  the  injured  area.  This  spasm  of  the  esophagus  may 
increase  and  form  a  complete  obstruction  and  the  patient  pass  into 
a  state  of  profound  shock ;  or  the  spasm  of  the  esophagus  may 
abate,  the  child  gradually  be  able  to  swallow  fluids,  and  in  a  few 
days  the  function  of  deglutition  return  to  the  normal.  This  happy 
outcome  often  gives  the  parents  a  false  sense  of  security — only  to 


CICATHICIAL    STENOSIS    OF    THE    ESOPHAGUS      413 

be  followed  later  by  a  stricture  due  to  cicatricial  contraction.  Then 
it  will  be  found  that  after  a  few  months  symptoms  of  obstruction 
again  appear.  At  first  badly  masticated  food,  then  semi-solid  food 
is  rejected,  and  finally  only  fluids  reach  the  stomach.  If  the  con- 
dition is  untreated  the  stenosis  becomes  progressively  worse  and  the 
child  dies  from  inanition. 

Diagnosis. — The  diagnosis  is  simple  when  the  history  is  taken 
into  consideration  with  the  actual  regurgitation  of  food.  The  loca- 
tion of  the  stricture  is  determined  by  passing  an  esophageal  sound 
— as  large  a  sound  as  possible — the  smaller  sounds  are  apt  to  catch 
in  the  folds  of  the  mucous  membrane.  It  must  not  be  forgotten 
that  in  esophagoscopy  we  have  an  excellent  means  of  determining 
the  extent  and  shape  of  the  constriction  and  the  subsequent  progress 
of  the  treatment.  Exploration  of  the  esophagus  must  be  conducted 
with  the  greatest  prudence.  We  are  dealing  with  an  injured  tube 
whose  walls  are  rendered  inelastic  and  friable  over  the  stenosed 
area,  and  ill-conducted  instrumentation  may  result  in  death. 

Treatment. — In  recent  burns  of  the  esophagus  the  injured  part 
must  be  put  at  rest  for  a  few  days.  The  spasm  of  the  esophagus, 
which  occurs  when  attempts  are  made  to  swallow  fluids,  is  the  best 
indication  that  nature  resents  forced  deglutition.  In  the  mean- 
time the  child  should  be  given  saline  injections  per  rectum  at  fre- 
quent intervals.  After  two  or  three  days  try  small  quantities  of 
albumin  water  and  milk  by  mouth.  If  spasm  is  still  present  it 
may  be  allayed  by  the  administration  of  a  small  dose  of  morphin 
hypodermically.  Sometimes  a  catheter  may  be  passed  into  the 
stomach  and  nourishment  introduced  by  this  means.  If  these 
measures  prove  futile  it  will  be  necessary  to  do  a  gastrostomy.  This 
operation  in  children  is  neither  more  difficult  nor  more  dangerous 
than  in  the  adult  (Froelich).  Through  this  opening  milk  or  egg 
albumin  water  may  be  introduced  by  means  of  a  catheter  three  or 
four  times  a  day. 

After  the  nutrition  of  the  child  is  assured,  it  will  be  necessary 
to  consider  dilatation  of  the  esophagus.  Three  or  four  weeks  after 
the  initial  accident  esophagoscopy  should  be  done  to  determine  the 
exact  nature  of  the  lesion  and  the  cautious  passage  of  esophageal 


414  THE  ESOPHAGUS 

bougies  should  be  commenced  to  prevent  contractile  stricture.  If 
stenosis  is  already  present  progressive  dilatation  with  esophageal 
bougies  should  be  employed.  Beginning  with  the  smallest  bulb  that 
will  pass,  the  size  is  increased  every  three  or  four  days  until  a 
diameter  of  one  centimeter  is  reached.  The  dilatation  should  never 
be  forced,  and  the  safest  plan  may  be  to  practise  dilatation  under 
control  of  the  esophagoscope  or  to  cautiously  nick  the  stricture  with 
an  esophagotome  when  it  is  particularly  dense. 

In  permanent  stricture  retrograde  dilatation  may  be  employed. 
"The  stomach  is  opened  and  a  strong  linen  string  is  passed  through 
the  stricture,  one  end  of  the  string  is  brought  out  through  the  open- 
ing in  the. stomach  and  the  other  through  the  mouth.  The  stricture 
is  made  tense  by  a  conical  bougie  and  is  then  divided  by  rapidly 
drawing  the  string  up  and  down  with  a  sawing  movement.  The 
string  is  withdrawn  and  the  external  wound  closed.  Recurrence 
is  prevented  by  the  frequent  introduction  of  esophageal  bougies." 
(Gottstein.) 

It  must  be  remembered  that  a  child  affected  with  cicatricial 
stricture  of  the  esophagus  is  never  definitely  cured  by  dilatation ; 
even  when  sufficient  caliber  has  been  obtained  it  is  necessary  from 
time  to  time  to  pass  a  bougie  to  prevent  recurrence. 


SECTION  XI 

THORAX  AND   SPINE 

CHAPTER  LI 

CONGENITAL    AFFECTIONS    OF    THE    THORAX    AND    SPINE 

MALFORMATIONS    OF    THE    THORAX 

Absence  of  the  Sternum. — Cases  are  reported  of  total  or  partial 
absence  of  the  sternum,  compatible  with  life.  In  such  instances 
the  anterior  thoracic  wall  is  incomplete  and  in  the  median  line  we 
note  a  simple  membrane  covered  with  integument.  On  each  side, 
the  ribs  terminate  by  a  free  extremity  or  are  connected  with  the 
ribs  of  the  opposite  side  by  a  fibrous  membrane  which  acts  as  a 
substitute  for  the  sternum. 

Cleft-Sternum. — It  will  be  recalled  that  the  sternum  is  developed 
in  lateral  halves.  When,  because  of  lack  of  development,  the  two 
halves  fail  to  fuse  in  the  median  line  we  have  a  condition  of  cleft- 
sternum  which  may  give  rise  to  displacements  of  the  viscera  behind. 
Again,  at  the  lower  part  of  the  sternum  near  the  ensiform  appendix 
in  the  median  line,  there  sometimes  exists  a  round  orifice — the 
sternal  foramen — sometimes  large  enough  to  admit  the  little  finger. 
This  orifice  may  establish  communication  between  a  mediastinal 
abscess  and  the  exterior,  or  subcutaneous  abscess  may  invade  the 
cellular  tissue  behind  the  sternum. 

Pigeon  Breast. — Pigeon  breast  is  an  abnormal  projection  of  the 
sternum  beyond  the  level  of  the  ribs.  It  presents  an  appearance 
as  if  the  thorax  had  been  pressed  together  from  both  sides,  i.  e.,  the 
transverse  diameter  is  diminished  and  the  anteroposterior  diameter 
increased.  On  both  sides  of  the  sternum  from  the  second  to  the 
eighth  rib  we  find  a  depression  or  groove. 

415 


416          AFFECTIONS  OF  THE  THORAX  AND  SPINE 

Many  theories  have  been  advanced  to  explain  this  deformity, 
but  the  real  cause  is  not  well  understood.  It  is  to  be  noted  that 
this  deformity  is  associated  with  the  stigmata  of  rachitis  such  as 
beading  of  the  ribs,  bow  legs,  etc.,  and  an  abnormal  softness  of  the 
bones  is  undoubtedly  a  necessary  condition  for  its  development, 
yet  the  special  deformity  remains  unexplained. 

Pigeon  breast  as  a  rule  is  only  a  cosmetic  defect  and  there  is  no 
increase  of  deformity  in  the  process  of  growth. 

TREATMENT. — This  deformity  may  be  considerably  modified  if 
treatment  is  begun  early  while  the  ribs  and  sternum  are  still  soft. 

Deep  breathing  with  manual  compression  of  the  thorax,  anti- 
rachitic  remedies,  light  gymnastics  for  developing  the  chest  walls 
will  assist  in  obliterating  the  deformity. 

Funnel  Chest. — Funnel  chest  is  a  sinking  in  of  the  anterior  chest 
wall  in  the  median  line.  It  may  vary  from  a  slight  groove  to  a  de- 
pression deep  enough  to  hold  a  man's  fist.  It  is  really  a  kyphosis 
of  the  sternum  and  in  extreme  cases  markedly  decreases  the  antero- 
posterior  diameter  so  that  the  viscera  are  displaced. 

The  cause  of  this  deformity  is  probably  intrauterine  pressure. 
The  chin,  elbow,  or  foot  pressing  against  the  sternum  in  utero 
would  be  the  plausible  explanation  of  such  a  malformation.  Yet 
it  may  be  a  developmental  defect  since  its  hereditary  tendency  is 
well  authenticated. 

TREATMENT. — The  treatment  of  this  defect  is  very  limited. 
Deep  breathing  and  light  gymnastics  for  developing  the  chest  may 
bring  about  improvement,  but  no  perfect  result  has  been  reported. 


SUPERNUMERARY   CERVICAL    RIBS 

The  most  frequent  appearance  of  this  phenomenon  and  the  most 
interesting  from  a  surgical  standpoint  is  that  of  the  seventh  cervical 
rib.  It  springs  from  the  transverse  process  of  the  seventh  cervical 
vertebra  and  may  be  found  on  one  or  both  sides  but  unequally 
developed. 

Surgically,   it   presents   an   exostosis   occupying   the    subclavian 


SPINA    BIFIDA 


417 


fossa  and  independent  of  the  clavicle.  It  may  compress  the  vessels 
and  nerves  beneath  the  clavicle,  causing  pain  and  weakness  of  the 
upper  extremity.  It  may  produce  distortion  of  the  neck  and  spine, 
torticollis,  and  lateral  curvature. 

On  examination  there  is  found  a  bony  prominence  above  the 
clavicle,  in  association  with  which  may  be  felt  the  pulsations  of 
the  subclavian  artery.  All  doubt  as  to  diagnosis  will  be  cleared 
away  by  a  radiograph. 

Treatment. — If  serious  symptoms  are  present  complete  extirpa- 
tion of  the  rib  should  be  performed.  It  is  well  worth  noting  that 
this  anomalous  rib  is  frequently  adherent  to  the  pleural  cul-de-sac, 
and  delicate  dissection  will  be  necessary  to  free  it. 


SPINA   BIFIDA 


Spina  bifida  is  a  hernia-like  protrusion  of  the  contents  of  the 
spinal  canal  through   a   congenital   defect   of  one   or  more  of  the 
vertebral  arches.     The  her- 
nia is  formed  by  some  of 
the  spinal  membranes  and 
contains  cerebrospinal 
fluid  with  or  without  the 
cord  or  nerve-roots.     (Fig. 
147.) 

Location. — It  is  essen- 
tially a  congenital  bony 
defect  of  the  spinal  canal 
and  is  frequently  associ- 
ated with  other  deformi- 
ties, such  as  club-foot,  cleft 
palate,  etc.  While  this 


FIG.  147. — SPINA  BIFIDA. 


congenital  defect  may  oc- 
cupy  any   portion    of   the 

spinal  canal,  it  is  most  frequently  situated  in  the  lumbosacral  region, 
rarely  in  the  cervical,  exceptionally  in  the  dorsal  region.     In  very 


418          AFFECTIONS  OF  THE  THORAX  AND  SPINE 

rare  instances  the  bony  defect  is  situated  anteriorly  and  there  is  a 
forward  intrapelvic  protrusion  of  the  contents  of  the  spinal  canal. 
These  cases  are  rarely  diagnosed  except  during  abdominal  operations. 

The  tumor-like  mass  is  sessile  or  slightly  pedunculated,  present- 
ing a  variable  volume,  usually  not  exceeding  the  size  of  an  orange  or 
tomato.  The  skin  covering  is  thin,  whitish,  of  a  cicatricial  aspect,  and 
often  umbilicated.  It  may  be  the  site  of  nevoid  stains  or  of  an  ul- 
cerated area  through  which  oozes  cerebrospinal  fluid.  The  skin  at  the 
periphery  of  the  tumor  becomes  thicker  and  is  often  encircled  by  a 
"collarette  of  hair."  The  sac  of  the  hernial  protrusion  is  formed 
from  the  arachnoid  membrane  since  the  dura  mater  participates  in 
the  bony  defect.  The  content  of  the  sac  consists  of  cerebrospinal  fluid 
with  or  without  the  cord  or  nerve  roots.  Spina  bifida  is  frequently 
associated  with  hydrocephalus,  which  suggests  a  fundamental  disturb- 
ance of  the  cerebrospinal  circulation  as  the  causative  factor  in  these 
developmental  defects. 

Anatomical  Classification. — Spina  bifida  may  rationally  be  di- 
vided according  to  its  anatomical  characteristics. 

(a)  Spinal  meningocele  contains  only  cerebrospinal  fluid.     It 
forms  a  globular  tumor,  usually  pedunculated,  and  as  the  sac  con- 
tains no  nervous  elements  it  is  not  associated  with  motor  or  sensory 
disturbances. 

(b)  Myelomeningocele   contains  fluid  with   flattened  cord    and 
nerve  roots  spread  out  over  the  dorsal  aspect  of  the  sac.     The  tumor 
is  flattened   and  umbilicated   at  the  center.      This   form  of  spina 
bifida  is  associated  with  extensive  defects  of  innervation  caused  by 
tension  on  the  nerve  roots  (paralysis  of  lower  extremities,  bladder, 
and  rectum). 

(c)  Myelocystocele  is  a  hernial  protrusion  due  to  fluid  accumu- 
lating in  the  central  canal  (intramedullary),  so  that  the  hernia  is 
formed  by  the  distended  cord  itself  lining  the  sac.     The  skin  cover- 
ing is  often  strongly  pigmented  and  covered  with  a  growth  of  hair. 
This   variety   is    frequently    associated   with   other    malformations; 
notably  defects  of  the  anterior  abdominal  wall,  bladder,  etc. 

Symptoms. — The  presence  of  a  congenital  tumor  over  the  spinal 
canal,  associated  with  nervous  disturbances,  should  give  us  the  key 


SPINA    BIFIDA 


419 


to  the  character  of  the  tumor.  Note  that  the  tension  of  the  tumor 
varies  with  posture,  and  that  its  volume  increases  when  the  child 
coughs  or  cries.  Pressure  over  the  tumor  causes  swelling  of  the 
fontanelles,  and  sometimes  a  partial  reduction  of  the  tumor  is  fol- 
lowed by  convulsions.  In  soft  compressible  sacs  the  bony  defect 
may  be  palpated  or  it  may  be  revealed  by  the  X-ray. 

Functional  disturbances  vary  according  to  the  character  of  the 
tumor.  In  severe  cases  there  are  paraplegia  and  incontinence  of 
urine  and  feces.  Remember  that  all  spina  bifida  have  not  the  same 
structure,  hence  the  diverse  symptoms. 


FIG.  148. — ULCERATING  SPINA  BIFIDA. 

Diagnosis. — The  diagnostic  points  are  its  congenital  origin,  its 
position,  and  its  variable  tension.  A  diagnosis  of  the  variety  of 
spina  bifida  is  not  very  certain  except  by  exploratory  incision. 

Prognosis  is  grave.  Life  is  constantly  threatened  through  infec- 
tion of  the  meninges,  rupture  of  the  sac,  and  urinary  sepsis.  (Fig. 
148.)  The  majority  of  cases  die  early.  Those  that  survive  are  the 
meningoceles. 

Treatment. — (a)  Protect  the  tumor  from  injury  by  a  suitable 
shield  of  leather  or  celluloid  held  by  adhesive  straps,  (b)  Advise 
operation  unless  it  is  contraindicated  by  extensive  paralysis  or 
hydrocephalus — operation  does  not  relieve  paralysis.  Explain  to 


420 


AFFECTIONS  OF  THE  THOKAX  AND  SPINE 


the  parents  that  the  gravity  of  the  condition  warrants  the  risk  of 
operation  and  that  the  result  may  be  fatal.  Operation  for  meningo- 
cele  has  given  the  most  favorable  results;  in  other  forms  the  results 
are  deplorable.  The  success  of  the  operation  depends  upon  the  char- 
acter of  the  tumor,  the  vitality  of  the  child,  and  the  simplicity  of 
procedure. 

OPERATION. — Have  the  patient's  head  low  so  as  to  anticipate 
sudden  loss  of  cerebrospinal  fluid.  Make  elliptical  incision  through 
the  skin  so  as  to  excise  the  central  portion.  Separate  the  sac  down 

to  the  pedicle.  Open  the 
sac,  isolate  nerve-roots  if 
present,  and  replace  them 
in  the  vertebral  groove.  Li- 
gate  the  base  of  sac  with 
catgut,  or,  if  too  broad,  su- 
ture and  excise  it.  Close 
the  defect  by  fascial  flaps 
and  suture  the  skin. 

Spina  bifida  occulta  is  a 
condition  in  which  a  bony 
defect  is  present  without  a 
protrusion  of  the  contents 
of  the  spinal  canal.  There 
is  a  vertebral  defect  with- 

FIG.  149.-SPINA  BIFIDA  OCCULTA.  (Phillips.)        out  the  presence  of  a  tumor. 

The  situation  of  the  defect  is  in  the  lumbosacral  region  and  is  in- 
dicated only  by  pigmentation  of  the  skin  and  a  patch  of  hair,  which 
often  grows  to  such  a  length  as  to  resemble  a  tail.  (Fig.  149.) 

While  many  of  these  cases  present  no  symptoms  except  tho 
cutaneous  stigmata,  there  are  others  in  which  there  is  partial  paraly- 
sis of  the  lower  extremity — bladder  and  rectum — caused  by  a  rudi- 
mentary development  of  the  spinal  canal,  as  shown  by  the  presence 
of  fibrous  bands,  which  pass  through  the  defect,  connecting  the 
lower  end  of  the  cord  with  the  skin.  As  the  child  grows  those 
bands  pull  upon  the  cord  and  cause  the  paralytic  symptoms.  This 
defect  is  often  complicated  by  such  neoplasms  as  lipomata,  angio- 


CONGENITAL    SACEOCOCCYGEAL    TOIOIJS  4il 

mata,  dermoids,  etc.,  and  when  they  develop  inside  the  canal  they 
produce  pressure  on  the  cord. 

TREATMENT. — Unless  symptoms  of  paralysis  are  present  no 
surgical  intervention  is  required.  In  the  presence  of  a  complicat- 
ing tumor,  or  of  fibrous  bands  causing  compression,  their  extirpa- 
tion is  clearly  indicated. 


CONGENITAL  SACROCOCCYGEAL  TUMORS 

Etiology  and  Pathology. — Congenital  sacrococcygeal  tumors  be- 
long to  the  group  of  teratomata.  They  may  or  may  not  be  asso- 
ciated with  meningocele.  Their  mode  of  origin  is  still  under  dis- 
cussion. One  school  claims  that  they  are  the  result  of  misplace- 
ment of  germinal  fragments,  while  others  contend  that  it  is  of  bi- 
germinal  origin,  i.  e.,  that  such  a  tumor  represents  an  incomplete 
monstrosity  of  twins. 

The  data  obtained  from  both  the  gross  and  microscopic  examina- 
tion of  these  tumors  gives  evidence  in  support  of  either  of  these 
claims.  Those  who  believe  in  the  monogerminal  origin  hold  that 
cell  inclusions  occur  when  the  dorsal  surface  of  the  early  embryonic 
mass  folds  itself  to  form  what  in  the  future  is  to  be  the  spinal  canal. 
The  fact  that  the  skin  attaches  itself  very  early  in  the  sacrum,  and 
may  thus  become  inclosed  below  the  cutaneous  surface,  is  thought 
to  be  a  strong  reason  for  the  occurrence  of  these  dermoid-like 
tumors. 

On  the  other  hand,  the  finding  in  these  tumors  of  such  forma- 
tions as  a  complete  limb,  portions  of  a  skull,  eyes,  trachea,  etc.,  is 
argued  by  the  bigerminal  advocates  as  proof  that  the  existent  fetus 
had  in  its  early  career  included  the  products  of  another  fecundated 
ovum. 

However  it  be,  these  growths  are  polycystic,  have  a  fibrous  basic 
structure,  and  contain  various  secretions,  chiefly  the  fatty,  grumous 
material  so  characteristic  of  dermoids.  Because  they  sometimes 
contain  neuroglia  and  ganglionic  cells  they  have  also  been  called 


422          AFFECTIONS  OF  THE  THORAX  AND  SPIXE 

neuroepitheliomata.  In  size  they  may  vary  from  a  pea  to  that  of 
a  child's  head.  (Fig.  150.) 

Situation. — They  are  usually  situated  in  the  mid-dorsal  line  of 
the  sacrum  (which  bone  may  at  times  be  reduced  to  a  mere  shell 
of  horseshoe  shape)  at  its  junction  with  the  coccyx.  If  the  tumor 
be  at  all  large  the  coccyx  is  absent. 

Sometimes  these  tumors  are  situated  in  front  of  the  sacrum  or 
coccyx,  and  then  give  symptoms  of  intrapelvic  pressure.  Cases 
are  on  record  where  the  latter  growths  have  discharged  their  con- 
tents into  the  rectum.  Steinthal  quotes  Kroner  and  Marchand 


FIG.  150. — SACRAL  TUMOR  BEFORE  OPERATION. 

(v.  Bergmann,  "System  of  the  Practice  of  Surgery")  in  a  very 
interesting  report  of  a  girl,  20  years  of  age,  who  had  an  anterior 
sacral  meningocele,  closely  resembling  a  cyst  of  the  broad  ligament. 
This  tumor  was  first  aspirated,  then  opened  and  drained;  death 
followed  with  symptoms  indicating  meningitis. 

Of  considerable  interest  are  those  cases  where  a  congenital 
fistula  has  existed  in  the  sacral  region,  proving  refractory  to  the 
ordinary  surgical  methods,  but  upon  radical  operation  is  found  to 
communicate  with  a  teratoma,  either  in  the  sacrum  itself  or  in  the 
presacral  tissues.  In  one  such  instance,  recently  reported  by  Keen 
and  Coplin,  the  X-ray  demonstrated  the  presence  of  extra  segments 
of  lumbar  vertebra  besides  fetal  parts  of  the  original  teratoma. 


CONGENITAL  SACEOCOCCYGEAL  TUMOIJS 


423 


From  the  data  of  their  case  the  existence  of  a  triple  monstrosity 
may  well  be  assumed. 

Symptoms. — These  tumors  are  most  frequently  found  in  girls. 
They  are  sessile  or  pedunculated,  grow  to  a  considerable  volume, 
and  are  prone  to  ulcerate.  It  must  be  remembered  that  these  tumors 
not  only  grow  externally,  but  also  grow  internally,  encroaching 
on  the  pelvis,  and  often  compromising  both  the  rectum  and 
bladder. 

Diagnosis. — In  diagnosing  these  tumors  we  must  eliminate  spina 
bifida  by  the  absence  of  its  car- 
dinal symptomatic  features — re- 
ducibility,  compression,  tension 
in  fontanelles,  and  paralyses. 
Always  make  a  rectal  examina- 
tion in  these  cases  to  recognize 
any  intrapelvic  prolongation  of 
the  growth. 

Treatment. —The  only  treat- 
ment of  any  avail  is  operative ; 
and  in  uncomplicated  cases  the 
results  are  excellent  (Fig.  151). 
Make  the  skin  incisions  ample 
to  get  at  the  large  pedicle  and 
placed  as  far  as  possible  from, 
the  anal  orifice.  Observe  care- 
fully hemostasis  of  the  pedicle, 
which  is  large  and  receives  ves- 
sels from  the  median  sacral  ar- 
tery. 

Dissection  of  the  intrapelvic 
lobe  must  be  conducted  with  prudence. 

Dress  the  wound  with  aristol  and  collodion,  and,  over  this,  gauze 
and  oil  silk.  Change  the  dressings  frequently  in  order  to  keep  the 
wound  scrupulously  clean,  as  an  infection  of  the  wound  may  be 
fatal. 


FIG.    151. — SHOWING    KESULT    AFTER    RE- 
MOVAL OF  SACRAL  TUMOR. 


'424          AFFECTIONS  OF  THE  THORAX  AND  SPINE 

PARACOCCYGEAL  FISTULJE 

In  many  subjects  there  exists  a  slight  cutaneous  depression  in 
the  sacrococcygeal  region,  which  never  gives  rise  to  unpleasant 
symptoms,  but  remains  simply  a  harmless  malformation.  When, 
however,  the  depression  is  deeper,  the  hair  and  sebaceous  glands 
may  be  the  site  of  irritation,  inflammation,  suppuration,  and  the 
formation  of  a  fistulous  tract.  If  the  pus  is  abundant  it  dissects 
up  the  neighboring  tissues,  produces  secondary  fistulous  tracts,  and 
presents  a  picture  which  may  simulate  osteopathic  fistulse.  These 
fistulse  are  to  be  differentiated  from  those  of  bony  origin  by  the  his- 
tory and  the  evidence  of  cutaneous  invagination. 

Treatment. — The  application  of  caustics  is  of  little  value.  Care- 
ful dissection  of  the  fistulous  tract  and  the  walls  of  the  primary 
focus  is  the  only  guarantee  of  a  cure. 


CONGENITAL    DIAPHRAGMATIC  HERNIA 

Congenital  diaphragmatic  hernia  is  rare.  To  appreciate  this 
condition  it  must  be  recalled  that  the  diaphragm  is  developed  in 
two  segments:  the  anterior  portion  is  formed  by  the  primary  dia- 
phragm, or  septum  transversum;  the  posterior  portion  develops 
much  later,  and  in  the  process  of  occlusion  it  is  the  space  at  the 
costovertebral  angle  that  is  the  last  to  be  covered  in.  Thus  develop- 
mental defects  in  the  anterior  portion  of  the  diaphragm  are  rare ; 
they  are  also  rare  on  the  right  side  because  of  the  presence  of  the 
liver. 

Location. — The  principal  positions  in  which  these  defects  are 
found  are:  (a)  At  the  costovertebral  angle,  (b)  At  the  normal 
orifice  between  the  sternal  and  costal  portions  of  the  diaphragm 
which  transmits  the  internal  mammary  artery.  Hernias  in  this 
position  pass  into  the  anterior  mediastinum,  (c)  At  the  esophageal 
opening,  (d)  At  the  opening  for  the  sympathetic  cord. 

Hernias  never  occur  at  the  opening  for  the  inferior  vena  cava. 


CONGENITAL    HERXTA    OF    THE    LUX({  4->r> 

Two  conditions  may  be  present  according  as  the  hernia  has  a 
sac  or  not.  If  the  pleura  and  peritoneum  are  fused  at  the  edge  of 
the  orifice  the  contents  of  the  abdomen  can  pass  into  the  thorax 
without  a  sac  (false  hernia).  When  the  defect  in  the  diaphragm  is 
closed  by  a  union  of  the  pleura  and  peritoneum  the  hernia  possesses 
a  sac  formed  by  the  united  layers  of  pleura  and  peritoneum  (true 
hernias).  The  true  diaphragmatic  hernias  are  comparatively  rare. 

It  is  well  to  remember  that  these  congenital  hernias  are  usually 
on  the  'left  side  and  that  they  may  contain  all  the  abdominal 
organs  with  the  exception  of  the  bladder  and  kidneys — rarely  the 
liver. 

Symptoms. — Most  .of  the  children  affected  with  this  form  of 
hernia  die  soon  after  birth.  In  the  cases  that  survive  the  true 
anatomical  condition  is  not  suspected  until  later,  when  symptoms 
of  intestinal  obstruction  present,  usually  attributed  to  causes  other 
than  that  of  developmental  defect  of  the  diaphragm. 

However,  such  a  possible  defect  should  be  kept  in  mind  when 
there  is  retraction  of  the  abdomen ;  when  the  left  half  of  the  thorax 
gives  a  tympanic  note  on  percussion  and  intestinal  gurgling  on 
auscultation,  when  the  heart  is  markedly  displaced  to  the  right, 
and  the  patient  presents  symptoms  of  dyspnea,  cyanosis,  digestive 
disturbance,  .pain,  vomiting,  and  constipation. 

Treatment. — Theoretically  surgical  intervention  is  indicated  if 
the  diagnosis  is  possible.  Since  reduction  has  been  found  impossible 
through  a  laparotomy  wound  the  operation  should  contemplate  a 
resection  of  the  ribs,  using  the  sternocostal  articulation  as  a  hinge 
for  the  flap,  so  that  the  hernia  may  be  approached  from  the  thoracic 
side.  After  a  reduction  of  the  hernia,  an  attempt  should  be  made 
to  close  the  diaphragmatic  defect.  This  is  not  always  possible  by 
means  of  sutures,  and  some  authors  advise  sewing  the  stomach  in 
the  hernial  orifice. 

CONGENITAL    HERNIA    OF    THE    LUNG 

In  certain  congenital  defects  of  the  chest  wall  there  may  be 
present  such  hernial  protrusions  of  the  lung  as  to  constitute  a 
monstrosity  and  be  incompatible  with  life. 


426  EMPYEMA 

As  a  rule,  however,  the  child  is  born  with  a  defect  of  the 
thoracic  wall  and  the  hernia  is  developed  some  days  later.  Us 
presence  is  marked  by  a  small  elastic  tumor,  which  increases  on 
expiration  and  decreases  on  inspiration.  The  tumor  is  reducible 
and  when  compressed  between  the  fingers  gives  the  sensation  of 
gaseous  crepitation. 

Treatment  consists  in  reducing  the  mass  and  retaining  it  by 
means  of  a  compress  and  bandage. 


OHAPTEE  LIT 

EMPYEMA 

Empyema  (purulent  pleurisy)  is  very  frequent  in  children  and 
presents  special  points  of  interest  which  merit  careful  consideration. 

Empyema  is  usually  met  with  in  very  young  children  (before 
the  age  of  five).  It  is  even  frequent  in  the  new-born  where  it  is 
rarely  diagnosticated  and  is  revealed  only  by  autopsy. 

Empyema  in  the  child  is  usually  the  result  of  a  pneumococcus 
infection.  It  is  true  that  it  may  be  the  result  of  a  tuberculous,  a 
staphylococcus,  or  streptococcus  invasion,  but  the  pneumococc'iis 
variety,  following  a  lobar  or  bronchopneumonia,  is  typical  of  child- 
hood. 

Empyema  in  the  child  is  usually  an  acute  process.  We  rarely 
encounter  the  chronic  type.  The  thorax  of  the  child  is  supple  and 
elastic,  there  is  a  tendency  for  the  parietal  and  visceral  pleura  to 
approximate,  which  opposes  the  formation  of  a  suppurating  cavity 
with  rigid  walls.  Hence,  the  thoracoplastics  of  Estlander,  etc.,  or 
the  decortication  of  the  lung  is  rarely  if  ever  needed. 

Special  Features  of  Symptoms. — Where  there  is  a  considerable 
collection  of  pus  absolute  dulness  is  the  natural  consequence;  not- 
withstanding this,  vesicular  breathing  is  persistent. 

Again  the  elasticity  of  the  child's  thorax  renders  the  swelling 
and  deformity  marked  in  comparing  the  two  sides. 

Aside   from  the   above  exceptions   the   local   and   constitutional 


TREATMENT  427 

symptoms  do  not  differ  from  the  manifestations  of  the  same  disease 
in  the  adult. 

Diagnosis. — The  use  of  the  antiseptic  puncture  will  eliminate 
diagnostic  errors. 

Prognosis. — The  prognosis  of  pneumococcus  empyema  is  most 
favorable.  Spontaneous  cures  have  occurred:  (a)  by  absorption  of 
the  pus;  (b)  by  discharge  into  the  bronchi,  when  it  is  vomited  and 
coughed  up;  (c)  by  discharge  through  an  external  opening  after 
perforation  of  the  thoracic  wall  (empyema  necessitatus). 

While  this  spontaneous  evolution  of  empyema  in  the  child  is  not 
at  all  exceptional,  it  should  not  deter  the  surgeon  from  prompt 
evacuation  of  the  pus  by  operative  measures.  A  high  mortality  is 
the  penalty  of  procrastination,  or  at  best  a  crippled  lung,  or  con- 
traction of  the  chest,  which  results  in  a  pronounced  scoliosis. 

Treatment. — Early  operative  intervention  is  the  only  rational 
procedure  in  order  to  prevent  septic  poisoning  and  secondary  de- 
formities. 

In  the  management  of  these  cases  there  are  two  distinct  methods 
to  be  employed,  each  method  having  its  special  indications.  The 
choice  of  procedure  requires  surgical  discrimination,  together  with 
a  proper  estimate  of  the  patient's  vital  index  and  therapeutic  pos- 
sibilities. 

A.  RESECTION  OF  RIB. — Resection  of  rib  is  indicated  in  strong 
children  above  two  years  of  age. 

Operation. — A  general  anesthesia  is  not  only  superfluous  but 
dangerous.  A  local  anesthesia  (novocain  or  stovain)  is  sufficient 
for  the  operation,  which  requires  only  a  few  minutes. 

The  opening  into  the  chest  should  be  made  at  the  lowest  point. 
A  safe  guide  is  to  make  the  incision  in  the  posterior  axillary  line 
on  a  level  with  the  angle  of  the  scapula.  Always  make  a  pre- 
liminary aspiration  over  the  point  selected  for  incision  to  demon- 
strate the  presence  of  pus. 

A  short  incision  should  be  made  down  on  to  the  rib,  the  perios- 
teum separated,  a  periosteal  elevator  inserted  under. the  rib,  and 
about  a  half  to  three-quarters  of  an  inch  of  rib  removed  by  the 
costotome. 


428 


EMPYEMA 


After  removal  of  the  rib  the  pleura  is  opened  by  a  sharp-nosed 
artery  clamp  and  en  larked  to  admit  the  index  finger.  The  inserted 
finger  regulates  the  flow  of  pus  so  that  it  is  removed  slowly. 

Irrigation  is  not  only  superfluous,  it  is  useless  and  often 
harmful. 

Two  rubber  drainage  tubes  should  be  placed  in  the  wound  and 
securely  fastened  to  prevent  them  being  sucked  into  the  pleural 
cavity — an  accident  not  infrequent  and  always  disagreeable.  (Fig. 
152.) 

The  duration  of  the   discharge   varies — in  the   most   favorable 

cases  it  ceases  after  a  few  weeks, 
in  unfavorable  cases  it  may  ex- 
ist for  a  long  time.  The  earlier 
the  resection  is  made  the  quicker 
the  lung  expands  and  suppura- 
tion ceases. 

The  drain  should  be  removed 
when  the  discharge  is  so  trivial 
that  it  probably  comes  from  the 
drainage  tract. 

B.  INTERMITTENT  A  s  P  i  K  A- 
TION. — In  very  young  children 
with  lowered  vitality  the  safest 
procedure  is  to  employ  repeated 
aspirations  with  the  injection  of 
a  two  per  cent,  solution  of  forma- 
lin in  glycerin. 

Method. — Insert  an  aspirat- 
ing needle  about  two  fingers'  breadth  below  the  upper  border  of  pus 
and  withdraw  about  two  ounces  of  fluid.  Kepeat  the  aspiration  daily, 
going  down  one  intercostal  space  as  the  pus  recedes  until  no  more 
pus  is  found.  Every  third  day  inject  an  ounce  of  a  two  per  cent. 
solution  of  formalin  in  glycerin.  This  method  gives  excellent  results 
in  small  children  since  it  removes  only  a  small  portion  of  pus  at  a 
seance  and  thus  allows  the  lung  to  slowly  expand  and  fill  the  space. 
On  the  other  hand  a  total  removal  is  followed  by  rapid  exudation  and 


152. — DRAINAGE  TUBES  IN  WOUND 
AFTER  RESECTION  OF  RIB. 


BILATEKAL    EMPYEMA  429 

an  enormous  loss  of  serum  into  the  empty  cavity,  which  is  a  serious 
drain  on  the  vital  resources. 

After-treatment  is  a  very  important  adjunct  to  prevent  thoracic 
deformities  and  subsequent  scoliosis.  Breathing  and  gymnastic 
exercises  should  be  begun  early  and  even  some  thoracic  brace  may 
be  necessary  to  hold  the  trunk  in  a  normal  erect  position. 

Bilateral  Empyema. — Bilateral  empyema  is  found  almost  ex- 
clusively in  children.  The  two  sides  may  be  affected  simultaneously 
or  a  few  days  apart.  The  rule  of  treatment  is  the  same  as  in  uni- 
lateral empyema,  except  operation  should  never  be  done  on  the  two 
sides  at  one  seance. 

Double  empyema  is  a  grave  condition,  the  operative  risk  is 
great,  and  its  management  requires  surgical  discrimination. 


CHAPTEK  LIII 

CUEVATUEE    OF    THE    SPINE 

In  considering  the  curvatures  of  the  spine  due  to  disturbances  of 
growth,  one  must  not  lose  sight  of  the  important  role  which  the 
biological  facts  assume  in  explaining  certain  abnormal  deviations. 
In  the  process  of  evolving  a  biped  from  a  quadruped  certain  skeletal 
changes  and  adaptations  were  imposed  by  the  erect  posture.  It  is 
obvious  that  this  posture  makes  special  demands  upon  the  spinal 
column  in  carrying  weight  and  preserving  equilibrium. 

It  is  always  a  critical  time  in  the  life  of  the  child  when  it 
begins  to  walk  and  its  skeletal  tissues  assume  the  weight-bearing 
functions  of  the  erect  posture.  If,  in  addition  to  this,  the  build- 
ing material  of  the  skeleton  has  undergone  pathological  changes,  as 
in  rachitis,  it  is  obvious  that  the  bones  are  deprived  of  that  hard- 
ness and  power  of  resistance  needed  to  carry  weight  and  act  as 
levers.  Hence  it  is  that  this  abnormal  plasticity  under  the  pressure 
of  weight  and  the  active  pulling  of  the  muscles  results  in  curvatures 
of  the  bones. 

The  important  role  which  rachitis  plays  in  altering  the  building 


430  CURVATURE  OF  THE  SPINE 

material  of  the  skeleton  and  thus  threatening  growth  and  further 
development  is  not  confined  to  the  first  years  of  childhood;  it  casts 
its  shadow  into  the  period  of  puberty  and  acts  as  a  latent  stigma 
when  increased  activity  is  demanded  by  the  profound  evolutionary 
changes  to  which  the  body  is  subjected. 


THE  NORMAL  EVOLUTION   OF   THE   SPINAL   COLUMN 

In  the  quadruped  the  spinal  column  is  straight,  but  as  the  erect 
posture  is  assumed  certain  compensatory  curves  are  produced,  which, 
result  in  the  permanent  physiological  curves  of  the  spine.  At  birth 
the  spinal  column  is  straight,  but  when  the  child  begins  to  sit  up 
the  weight  of  the  head  causes  the  back  to  bend,  and  a  primitive 
spinal  curve  with  the  convexity  backward  is  produced ;  when,  how- 
ever, the  child  begins  to  stand  and  walk,  the  effort  to 
maintain  equilibrium  brings  into  play  the  muscles 
which  act  to  produce  compensatory  curves,  and  thus  is 
produced  the  normal  contour,  which  consists  of  a  long 
curve  in  the  dorsal  region  with  its  convexity  backward, 
and  the  two  compensatory  curves  in  the  cervical  and 
lumbar  regions  with  the  convexity  forward  (Fig.  153). 
These  curves  vary  greatly  within  physiological  limits 
and  are  modified  by  habit,  occupation,  and  sex. 

Again,  it  is  evident  that  the  normal  position  of  the 
spinal  column  is  maintained  by  the  continuous  coopera- 
tion of  the  muscles — thus  the  posterior  muscles  (erector 
spinaa)  endeavor  to  increase  the  lordosis,  while  the 
anterior  muscles  of  the  abdomen  (rectus  abdominis, 
etc.)  endeavor  to  increase  the  kyphosis  of  the  column. 
Note  also  the  influence  of  the  position  of  the  pelvis 
upon  the  form  of  the  spinal  column.  The  pelvis  is 
rigidly  fixed  to  the  spinal  column  through  the  sacro- 
FiG.153.— THE  iliac  articulation;  movement  of  the  pelvis  is  accom- 


TOTTB  or  THE  plished  through  the  hip  joint.     The  flexor  muscles  of 
SPINAL    COL- 
UMN. 


the  hip  lower  the  anterior  part  of  the  pelvis  and  the 


ABNOKMAL  POSITIONS    OF    SPINAL    COLUMN       431 

pelvic  plane  approaches  the  vertical;  the  extensors  of  the  hip  lower 
the  posterior  part  of  the  pelvis  and  the  pelvic  plane  becomes  more  or 
less  horizontal.  In  forward  bending  of  the  pelvis,  equilibrium  is 
maintained  by  a  strong  lumbar  lordosis,  which  bends  backward  the 
whole  spinal  column.  (Note  the  marked  lordosis  in  the  ultra-femi- 
nine figure  where  there  is  a  congenital  forward  tilt  of  the  pelvis.) 
When  the  pelvis  is  tilted  backward  equilibrium  is  maintained  by  a 
lumbar  kyphosis.  Hence  the  inclination  of  the  pelvis  has  an  impor- 
tant influence  upon  the  form  of  the  spinal  column,  and  its  importance 
will  be  observed  later  in  the  treatment  of  abnormal  positions  of 
the  spinal  column. 


ABNORMAL    POSITIONS    OF    THE    SPINAL    COLUMN 

A.  Kyphosis  (Deviation  with  a  Posterior  Convexity). — By  this 
is  meant  an  habitual  attitude  characterized  by  curvature  of  the 
spine  with  the  convexity  backward,  which  is  either  an  increase 
in  the  physiological  curve,  or  a  curve  due  to  some  pathological 
state. 

We  note  in  this  connection:  (a)  Rachitic  kyphosis,  most  marked 
in  the  lower  segment  under  the  form  of  a  dorsolumbar  kyphosis, 
found  in  early  childhood,  (b)  Postural  kyphosis — "round  shoul- 
ders"— most  marked  in  the  upper  dorsal  region,  seen  in  later  child- 
hood and  adolescence. 

RACHITIC  KYPHOSIS. — Rachitic  kyphosis  is  mainly  caused  by 
permitting  rachitic  children  to  assume  the  sitting  posture  too  early. 
The  inclination  toward  kyphosis  is  seen  when  the  child  is  carried 
on  the  arm;  a  too  high  pillow  or  a  too  soft  bed  will  cause  an  in- 
creased kyphosis  of  the  soft  rachitic  spinal  column.  (Fig.  154.) 

While  the  kyphosis  of  early  childhood  is  usually  not  fixed  and 
disappears  when  the  child  lies  down,  yet  it  may  become  rigid  and 
result  in  an  habitual  kyphotic  curve.  When  we  consider  that  fre- 
quently a  later  scoliosis  is  developed  from  a  rachitic  kyphosis,  the 
importance  of  early  treatment  is  obvious. 


432 


When  a  disposition  toward  kyphosis  is  observed  the  child  should 
be  placed  on  the  abdomen;  when  the  legs  are  lifted  a  pronounced 
lordosis  will  be  observed  in  the  normal  spine;  in  rigid  kyphosis  we 
note  a  pronounced  convexity. 

Prophylaxis. — When  a  child  exhibits  a  tendency  toward  rachitis 
special  care  should  be  exercised  in  regard  to  posture.  These  chil- 
dren should  lie  on  an  even,  hard  mattress.  They  should  not  be 
carried  on  the  arm;  nor  should  they  sit  in  the  baby  carriage  with 
the  knees  extended. 

Treatment. — After  the  kyphosis  has  been  developed  the  con- 
dition can  be  best  coun- 
teracted b  y  postural 
treatment  which  encour- 
ages lordosis.  Place  the 
child  on  the  belly  with 
a  pillow  under  the  chest 
and  thighs,  and  compel 
him  to  reach  up  for 
playthings.  The  over- 
stretched and  weakened 
muscles  of  the  back 
should  be  strengthened 
by  daily  massage.  In 
older  children  the  use  of 
a  rocking  chair  or  other 

appropriate    gymnastics 
Fro.  154.-RACHmc  KYPHOBIS.  (Spitzy.)  ^^  ^  prescribed> 

POSTURAL  KYPHOSIS. — "BOUND  SHOULDERS"  OF  SCHOOL  CHIL- 
DREN is  a  form  of  kyphosis  which  appears  during  the  school  years 
and  is  most  marked  in  the  upper  dorsal  vertebrae.  The  origin 
of  this  deformity  is  muscular  weakness.  It  will  be  recalled  that  the 
spine  is  held  in  its  proper  physiological  curve  by  a  proper  inn  sen!  ar 
balance;  there  must  be  continuous  action  of  the  erector  spiime  and 
the  flexors  and  extensors  of  the  hip.  In  children  with  a  weakened 
muscular  system  the  steady  pull  of  the  muscles  is  tiresome,  hence 
they  relax  and  allow  the  spinal  column  to  assume  a  position  in 


ABNORMAL    POSITIONS    OF    SPINAL   COLUMN       433 


which  the  muscles  are  passive — hence  the  kyphotic  position  of  the 
dorsal  and  lumbar  vertebrae. 

Again  this  muscular  relaxation  overstretches  the  posterior  part 
of  the  spinal  column  and  with  it  the  attached  ligaments,  the  inter- 
vertebral  cartilages  thin  out  in  front,  the  vertebrae  are  pressed  to- 
gether anteriorly,  and  the  way  is 
paved  for  diminished  movability 
of  the  column  and  ultimate  stiff- 
ness and  fixation. 

It  is  also  to  be  noted  that  the 
flexors  and  extensors  of  the  hip 
play  an  important  role,  since  re- 
laxation of  these  muscles  causes 
the  pelvis  to  drop  backward  until 
the  inclination  of  the  pelvis  is  so 
diminished  that  the  lumbar  lordo- 
sis  is  obliterated. 

These  children  also  allow  the 
shoulders  to  sink  downward  and 
forward  to  relieve  the  tiring  action 
of  the  shoulder  muscles.  The  ab- 
dominal muscles  are  lengthened 
and  thinned,  resulting  in  the  "pot 
belly"  of  abdominal  ptosis.  They 
are  the  thin,  frail,  weakly  chil- 
dren, with  round  shoulders,  con- 
tracted chests,  protuberant  abdomens,  who  later  become  the  neuras- 
thenic men  and  women.  (Fig.  155.)  Therefore,  it" is  obvious  that 
the  muscles  are  the  important  factors  in  "round  shoulders"  and  it 
is  the  recognition  of  this  fact  that  forms  the  basis  of  rational  treat- 
ment. 

Treatment. — The  rational  treatment  of  this  deformity  must 
contemplate  improvement  in  the  general  nutrition  combined  with 
some  system  of  gymnastic  exercises  which  will  straighten  the 
muscles  of  the  back,  shoulders,  and  hips. 

A  list  of  such  exercises  can  merely  be  suggestive;  they  must 


FIG.  155. — THE  FAULTY  POSTURE  RE- 
SULTING IN  THE  "POT-BELLY"  OP 
ABDOMINAL  PTOSIS.  (Reynolds.) 


434 


CURVATURE  OF  THE  SPINE 


be  modified  or  extended  to  suit  the  individual  needs.  First,  the 
child  should  be  taught  proper  posture.  The  relation  of  posture  to 
human  efficiency  is  not  sufficiently  appreciated,  as  is  well  illustrated 
in  the  faulty  posture  of  the  majority  of  men  and  women.  The 
relaxed  posture  with  the  forward  head,  round  shoulders,  hollow 
chest,  protuberant  abdomen,  with  the  viscera  crowded  down  in  front 
of  the  pelvis,  is  the  prevalent  posture.  This  chronically  bad  posture 

brings  about  mechanical 
disturbance  in  the  thoracic 
and  abdominal  viscera, 
which  in  time  leads  to  me- 
chanical  and  bacterial 
changes  and  finally  to 
chronic  disease. 

This  faulty  posture  is 
corrected  neither  by  braces 
nor  belts,  but  by  a  regen- 
e  r  a  t  e  d  muscular  system. 
Proper  posture  is  therefore 
the  first  essential  in  the 
treatment  of  these  cases. 
The  child  must  first  be 
taught  to  have  a  proper 
mental  conception  of  the 
military  position  (head 
erect,  chin  drawn  in,  shoul- 
ders thrown  back,  abdomen  retracted) — the  reverse  of  the  "round 
shoulder"  posture.  (Fig.  156.)  After  this  mental  picture  is  fixed 
by  precept  and  example  it  should  be  crystallized  into  habitual  mus- 
cular expression  by  proper  gymnastic  exercise  and  such  sports  as 
contribute  to  its  permanency. 

Some  modification  of  the  "setting-up"  exercises  of  the  military 
school  is  an  admirable  drill  to  follow.  Such  exercises  as  stretch 
and  bend  the  trunk,  performed  while  the  hands  are  behind  the  back, 
are  admirable.  (Fig.  157.)  Breathing  exercises  develop  the  chest 
and  increase  muscular  nutrition.  (Fig.  158.)  Such  sports  as  swim- 


FIG.  156. — FAULTY  AND  CORRECT  POSTURE. 


ABNOKMAL    POSITIONS    OF    SPINAL    COLUMN       435 


FIG.    157. — BENDING   EXERCISE   WITH   HANDS   BEHIND   THE   BACK 
FOR  THE  CORRECTION  OF  ROUND  SHOULDERS. 


FIG.  158. — BREATHING  EXERCISE  FOR  THE  CORRECTION  OF  ROUND  SHOULDERS. 
The  arms  are  drawn  back  in  inspiration,  and  forward  in  expiration. 


436 


CUKVATUKE  OF  THE  SPINE 


ming,  rowing,  and  skating  are  of  special  advantage.  If  there  is  a 
tendency  to  fixation  of  the  spine  special  exercises  must  be  prescribed 
to  stretch  the  anterior  part  of  the  column,  such  as  hanging  011  rings 
or  bars. 

Whatever  exercise  is  prescribed  its  efficacy  will  be  in  proportion 
to  its  regularity  and  the  demands  which  it  makes  upon  sunshine. 
and  fresh  air. 

Parents  and  teachers  should  give  special  attention  to  the  correct 

sitting  posture  of  the  child 
— and  this  attention  should 
begin  by  providing  a  proper 
kind  of  chair,  and  a  desk  of 
suitable  height.  The  ma- 
jority of  chairs  in  the  home 
are  made  for  ornament 
rather  than  utility.  Few 
are  hygienic  even  for  the 
adult,  none  are  provided  for 
the  child.  He  must  either 
stand  or  conform  in  a  pro- 
crustean  fashion  t  o  the 
choice  of  his  elders.  (Fig. 
159.) 

The  disproportion  be- 
tween the  chair  and  the 
child,  the  lack  of  proper 

back  rest,  the  use  of  unsuitable  desks  all  contribute  to  foster  the 
kyphotic  position. 

The  use  of  braces  should  be  discouraged.  All  braces  have  some 
objectionable  points,  the  most  serious  of  which  is  that  they 
prevent  the  action  of  the  muscles  involved  and  as  a  result  fa- 
vor atrophy  of  disuse.  The  best  brace  is  a  well-developed 
muscle. 

B.  Lordosis  (Deviation  with  a  Posterior  Concavity}. — Lordosis 
is  a  much  less  important  deviation  than  kyphosis  and  is  usually 
symptomatic  of  some  disease  or  deformity  either  of  the  spine  or 


FIG.  159. — FAULTY  SITTING  POSITION. 


ABNOEMAL    POSITIONS    OF    SPINAL   COLUMN       437 


its  adncxa.     Lordosis  is  observed  as  a  result  of  hip-joint  disease, 
congenital  dislocation  of  the  hip,  spondylitis,  etc. 

The  TREATMENT  of  these  lordoses  is  the  treatment  of  the  pri- 
mary cause  —  if  this  is  curable  then  the  lordosis  will  disappear  in 
those  cases  in  which  there  is  no  ankylosis.  The  lordosis  of  young 
rachitic  children  and  scoliotic  children  is  simply  an  expression  of 
the  general  bony,  muscular,  and  ligamentous  weakness,  which  must 
be  corrected  by  appro- 
priate therapeutic  and 
hygienic  measures. 

C.     Scoliosis  (Contin- 
u  o  u  s   Laterial   Devia- 

tion). —  By    the    term 

scoliosis    is    meant    an 

habitual    lateral    devia- 

tion of  the   spinal   col- 

umn accompanied  by  a 

rotation  of  the  vertebral 

bodies.     Thus  it  will  be 

noted  that  scoliosis  is  a 

double   lesion  —  it   is 

really  a  distortion,  the 

elements  of  which  are  a 

lateral  deviation  of  the 

spine  and  a  rotation  of 

its  segments.    The  spine  FlG   i60._scoLiosi8. 

is  not  only  bent,  it  is    Note  ,he  »ain 

twisted.    These  two 

facts  are  basic  in  appreciating  the  nature  of  scoliosis. 

As  Bradford  and  Lovett  observe,  scoliosis  is  not  a  disease  in 

any  true  sense,  but  a  distortion  of  growth.     The  deformity,  appears 

and  is  developed  during  the  growing  years,  the  largest  number  of 

cases  occurring  between  the  7th  and  10th  years. 

It  is  a  very  common  affection  —  statistics  show  that  about  25  per 

cent,  of  school  children  are  scoliotic.     It  seems  to  be  more  frequent 

in  girls  than  in  boys.     As  a  rule,  the  main  curvature  involves  only 


438  CURVATURE  OF  THE  SPINE 

one  part  of  the  column,  while  above  or  below  we  observe  compen- 
satory curves  which  are  directed  to  the  opposite  side  and  are  due 
to  an  attempt  to  reestablish  spinal  equilibrium  (Fig.  160). 

These  curvatures  in  the  spine  are  followed  by  changes  in  the 
contour  of  the  trunk;  on  the  convex  side  the  trunk  is  arched  out, 
on  the  concave  side  the  trunk  is  arched  in ;  thus  the  hip  of  the 
concave  side  is  more  prominent  and  is  spoken  of  as  "high  hip" 
while  in  curvatures  of  the  upper  segment  we  note  that  the  shoulder 
of  the  convex  side  is  more  prominent — "high  shoulder." 

ETIOLOGY  AND  PATHOLOGY. — It  is  obvious  that  the  erect  posture 
makes  special  demands  upon  the  spinal  column  in  carrying  weight 
and  preserving  equilibrium — "lateral  curvature  of  the  spine  is  one 
of  the  penalties  of  the  erect  posture."  It  is  essentially  a  deformity 
of  growth,  due  to  pressure  abnormally  distributed  upon  a  plastic 
spine.  It  is  not  easy,  however,  to  always  recognize  the  direct  cause 
of  this  deformity.  Those  commonly  found  are: 

(a)  Congenital  Scoliosis. — Not  so  infrequent  as  previously  sup- 
posed.    It  is  undoubtedly  due  to  the  fetus  being  held  in  a  faulty 
intrauterine  position,  caused  by  a  deficiency  of  liquor  amnii. 

(b)  Rachitic   Scoliosis. — Many   pronounced    forms    of   scoliosis 
are  to  be  traced  back  to  rachitis. 

(c)  Static   Scoliosis. — Inequality    in   the   length    of    the   limbs 
causes  obliquity  of  the  pelvis,  and  in  order  to  keep  the  trunk  in  a 
state  of  equilibrium,   the   spinal  column  must   develop   a  compen- 
satory curve.     This  condition  is  observed  in  congenital  dislocation 
of  the  hip,  hip  disease,  paralysis,  and  pronounced  deformities  affect- 
ing one  leg. 

(d)  Empyema,  scoliosis  occasionally  follows  a  chronic  empyema 
in    which    the    function    of    the    lung    is    obliterated    by    adhesions 
and  -the  side  of  the  chest  retracted.     As  a  result,  the  function  of  the 
unaffected   lung   is    increased    and    the   convexity    of   the    curve    is 
directed  toward  the  healthy  side. 

(e)  Paralytic  scoliosis — the  result  of  anterior  poliomyelitis.     The 
most  pronounced   cases   are  the  result    of    unilateral    paralysis  of 
the  muscles  of  the  trunk.     Here  the  convexity  of  the  curve  is  again 
directed  toward  the  healthy  side  since  the  function  of  the  disabled 


ABNORMAL    POSITIONS    OF    SPINAL    COLUMN       439 

side  of  the  thorax  is  compensated  by  increased  activity  on  the 
sound  side. 

(f)  Occupation  Scoliosis. — A  large  number  of  all  scolioses  are 
to  be  traced  back  to  certain  occupations  that  require  habitual  inclina- 
tion of  the  trunk.  This  is  observed  in  stone  cutters  and  carpenters, 
where  the  activity  of  the  muscles  is  exercised  in  one-sided  move- 
ments— in  violinists,  draftsmen,  school  children  carrying  books 
on  one  side,  false  position  in  writing,  etc. 

PATHOLOGICAL  ANATOM Y. — Although  the  pathological  anatomy 
has  been  carefully  investigated  there  is  still  much  that  is  unknown 
in  this  interesting  affection.  It  must  be  remembered  that  we  are 
dealing  with  a  deformity,  not  a  disease;  and  that  the  pathological 
factors  are  the  results  of  the  deformity  in  the  vertebrae  and  its 
secondary  effects  upon  the  trunk  and  its  contents. 

In  scoliosis  existing  for  a  short  time  there  is  slight  deviation 
from  the  normal — the  scoliosis  is  functional,  there  is  "lateral  curva- 
ture without  rotation."  In  long  existing  scoliosis  there  are  struc- 
tural changes  which  modify  the  form  and  function  of  the  spinal 
column.  Lateral  inclination  is  not  the  only  factor,  there  is  also 
vertebral  torsion.  The  intervertebral  cartilages  become  wedge- 
shaped,  and  the  bodies  of  the  vertebras  rotate  so  that  they  look 
toward  the  side  of  the  convexity  while  the  spinous  processes  point 
toward  the  concavity.  A  consideration  of  these  changes  is  practical 
only  in  so  far  as  the  clinical  conditions  are  concerned.  Among  the 
most  striking  secondary  deformities  of  lateral  curvature  is  that  of 
the  thorax. 

The  attached  ribs  must  necessarily  follow  the  direction  given 
by  the  distorted  vertebra;  and  it  must  be  recalled  that  these  verte- 
brae are  not  only  bent  but  twisted;  thus  it  is  that  on  the  convex 
side  the  ribs  are  drawn  backward  and  their  angles  project  beyond 
the  spinous  processes,  "sometimes  covering  and  concealing  them," 
while  on  the  concave  side  the  ribs  are  turned  forward,  brought 
closer  together,  and  the  intercostal  spaces  diminished  so  that  the 
ribs  may  be  in  actual  contact  (Fig.  161).  The  result  of  this  rota- 
tion is  to  considerably  diminish  the  capacity  of  the  chest  on  the  con- 
vex side,  so  that  the  greater  part  of  the  breathing  must  be  done 


440 


CURVATURE  OF  THE  SPINE 


with  the  lung  of  the  concave  side.  These  various  changes  in 
the  form  of  the  thorax  correspondingly  modify  its  capacity,  dis- 
place and  compress  its  contents,  and  compromise  their  vital  func- 
tion. 

This  compromised  pulmonary  function  is  evidently  the  cause  of 
the  frequently  observed  tuberculous  infiltration  of  the  apices  of  the 

lung.  Musser  found  in  100  cases  of 
scoliotic  children  53  affections  of  the 
apices  of  the  lung. 

In  pronounced  scoliosis  there  is  dis- 
placement of  the  heart,  while  the  great 
vessels  and  esophagus  following  the 
course  of  scoliotic  curve  are  more  or  less 
displaced. 

Intercostal  neuralgia  is  of  special 
practical  interest.  It  is  usually  found 
on  the  concave  side  and  is  the  result 
of  pressure  on  the  nerves  from  the  im- 
pinging ribs. 

SYMPTOMS. — The  onset  of  scoliosis 
is  usually  slow  and  insidious.  The 
earliest  intimation  that  these  patients 
give  is  the  characteristic  slouching  pos- 
ture which  they  assume.  They  seem  to 
sit  or  stand  without  any  muscular  grip 
on  themselves.  The  shoulders  are  re- 
laxed, they  always  lean  to  one  side  or 
the  other,  one  shoulder  is  higher  than  the  other.  Usually  it  is  when 
this  faulty  position  becomes  permanent  that  these  patients  are  first 
seen  by  the  surgeon. 

Examination. — These  cases  should  be  examined  with  great  care 
and  with  complete  exposure  of  the  posterior  aspect  of  the  trunk. 
The  clothes  should  be  removed  to  the  iliac  crests — in  girls  the  skirt 
may  be  fastened  by  a  belt  around  the  trochanters,  or  a  skirt  with 
an  elastic  top  band  should  be  provided.  The  patient  should  stand 
with  the  back  to  the  light,  the  hair  lifted  from  the  neck  and  the 


FIG.  161. — DISTORTION  OF  THE 
RIBS  IN  LATERAL  CURVATURE. 
(Bradford  and  Lovett.) 


ABNORMAL  POSITIONS    OF    SPINAL    COLUMN        4-11 

arms  hanging  naturally.  First,  inspect  the  posture  of  the  patient 
and  note  any  deviations  from  the  normal — even  slight  lateral  in- 
clinations will  produce  some  asymmetry  of  the  trunk.  !Mark  with 
a  soft  pencil  or  ink  the  spinous  processes,  the  iliac  crests,  and  the 
angles  of  the  scapula. 

Note :  Any  differences  in  the  height  of  the  shoulders ;  any  pro- 
jection of  the  scapulae;  the  relation  of  the  arms  to  the  sides,  and 
the  form  and  size  of  the  two  "brachio-thoracic  triangles" ;  any  dif- 
ference in  the  height  of  the  hips;  any  fullness  on  one  side  with  a 
corresponding  concavity  on  the  other. 

Compare  the  line  of  the  spinous  processes  with  a  plumb-line 
suspended  behind  in  the  line  of  the  cleft  of  the  buttocks ;  any 
lateral  deviation  is  evidence  of  scoliosis. 

The  flexibility  of  the  spine  should  be  tested.  Kirmisson  insists 
on  the  importance  of  not  neglecting  the  examination  of  the  feet 
since  scoliosis  is  often  connected  with  flat  foot ;  also  the  lower 
extremities  should  be  measured  "in  order  to  make  sure  that  there 
is  not  any  difference  in  length  between  them  which  cannot  be  ex- 
plained by  any  other  pathological  condition." 

Careful  records  of  the  deformity  should  be  kept  for  purposes 
of  comparison  in  the  future  history  of  the  case.  Whenever  pos- 
sible, photographs  of  the  back  should  be  made  with  the  patient  stand- 
ing behind  a  thread  screen.  Elmer's  method  of  recording  is 
simple  and  convenient.  "A  strip  of  adhesive  plaster  three 
inches  wide  is  laid  along  the  spine  from  the  vertebral  prominences 
to  the  sacrum.  The  spinous  processes  are  marked  and  outlined 
(Fig.  162).  The  plaster  is  then  removed,  backed  with  brown  paper, 
labeled  with  name  and  date,  and  filed  for  future  comparison." 
(Willard.) 

DIFFEEENTIAL  DIAGNOSIS. — There  is  a  possibility  of  confound- 
ing lateral  curvature  with  early  Pott's  disease,  especially  those 
atypical  cases  of  spinal  caries  with  a  lateral  tilt.  But  they  should 
not  be  difficult  to  differentiate  since  one  presents  a  clinical  picture 
of  disease,  the  other  of  deformity  only.  In  Pott's  disease  the  spine 
is  rigid,  the  patient  cannot  stoop  or  bend,  there  is  not  a  lateral 
curve  but  an  angular  tilt  to  one  side,  and  pressure  over  the  spinous 


'442 


CURVATURE  OF  THE  SPINE 


processes  produces  pain.  A  correct  diagnosis  is  of  the  highest  im- 
portance, since  the  gymnastic  exercises  so  important  in  scoliosis 
would  give  disastrous  results  in  Pott's  disease. 

PROGNOSIS. — It  must  be  remembered  that  scoliosis  is  a  de- 
formity of  growth,  hence  the  earlier  the  deformity  appears  the 
worse  the  prognosis.  Those  cases  which  appear  at  an  early  age  are 

more  serious  than  those  which 
develop  in  adolescence.  It 
should  be  well  understood  that 
scoliosis  can  never  be  corrected 
without  treatment.  It  is  a 
grave  error  to  treat  these  cases 
lightly  and  assure  the  parents 
that  the  child  will  outgrow  the 
deformity.  Spontaneous  cure 
of  a  true  scoliosis  does  not  occur. 
The  fate  of  a  scoliotic  child  de- 
pends upon  early  and  long-con- 
tinued treatment. 

PROPHYLAXIS. — In  the  pre- 
vention of  scoliosis  the  family 
physician  plays  an  important 
role.  The  discovery  of  the  de- 
formity when  well  advanced 
may  be  left  to  parents  or  nurse, 
but  the  discovery  of  the  tend- 


FIG.  162.- — METHOD  OF  APPLYING  AD- 
HESIVE STRIP  TO  BACK  ON  WHICH 
THE  LINE  OF  SPINOUS  PROCESSES 
Is  TRACED  WITH  PENCIL  FOR  FUTURE 
REFERENCE.  (Willard.) 


ency  to  deformity  should  be  an- 
ticipated by  the  supervising 
care  of  the  family  physician. 
He  should  be  on  the  lookout  for 
faulty  posture  and  examine  from  time  to  time  those  children  com- 
mitted to  his  care  in  whom  a  tendency  to  deformity  is  suspected. 

Special  vigilance  should  be  exercised  regarding  the  proper 
posture  of  the  child.  The  relaxed  posture  with  the  forward  head, 
round  shoulders,  hollow  chest,  protuberant  abdomen  is  the  forerunner 
of  spinal  deformity. 


ABNORMAL   POSITIONS    OF    SPINAL   COLUMN       443 

Good  nutrition,  strong  muscles,  correct  position  while  standing 
and  sitting,  proper  seats  and  desks  for  school  children,  open-air 
games  which  do  not  require  one-sided  muscle  work  are  the  best  pro- 
tection against  the  formation  of  scoliosis. 

TREATMENT. — As  soon  as  the  diagnosis  of  scoliosis  is  made 
there  is  presented  a  definite  and  difficult  problem,  for  the  solution 
of  which  the  family  physician  is  usually  responsible.  The  ques- 
tion arises  whether  all  these  cases  require  such  treatment  as  can 
be  obtained  only  in  an  orthopedic  clinic  or  even  under  the  super- 
vision of  an  orthopedic  surgeon.  Is  there  any  portion  of  these 
cases  that  can  be  properly  treated  by  the  physician  without  special 
orthopedic  training?  When  so  large  a  proportion  as  .25  per  cent 
of  all  school  girls  have  scoliosis  there  is  need  of  some  treatment 
adapted  to  at  least  a  portion  of  these  cases  which  can  be  effectively 
carried  out  under  the  supervision  of  the  family  physician.  If  we 
adopt  Lovett's  classification  of: 

(a)  Functional  or  postural  scoliosis — cases  without  marked  or- 
ganic change,  and 

(b)  Structural  or  habitual  scoliosis — cases  in  which  a  perma- 
nent change  has  taken  place  in  the  spine  and  soft  parts. 

We  have  a  rational  pathological  classification  and  one  which 
naturally  divides  the  cases  into  those  which  may  be  treated  under 
the  supervision  of  the  family  physician  and  those  that  require  the 
facilities  of  the  orthopedic  clinic  and  the  skill  of  the  orthopedic 
surgeon.  Thus  the  treatment  of  postural  or  functional  scoliosis 
may  be  properly  instituted  by  the  physician  without  special  ortho- 
pedic training,  providing  he  possesses  what  is  called  the 
"orthopedic  temperament,"  which  combines  perseverance  and 
patience. 

The  treatment  of  postural  scoliosis  is  essentially  hygienic  and 
gymnastic. 

The  first  consideration  is  to  eliminate  all  contributory  causes, 
such  as  errors  of  vision,  which  compel  children  to  incline  the  head ; 
differences  in  length  of  legs,  which  should  be  corrected  by  building 
up  the  short  leg  with  a  high  sole;  flat  foot,  etc. 

Next,  carefully  avoid  excessive  bodily  or  mental  fatigue.     Ar- 


444  CURVATURE  OF  THE  SPINE      ; 

range  the  day  so  that  the  periods  of  activity  arc  shortened,  the 
periods  of  rest  increased.  The  hours  of  study  should  be  so  arranged 
that  they  are  frequently  interrupted  by  periods  of  relaxation.  The 
chief  aim  should  be  to  teach  the  child  proper  posture,  and  to  give 
it  permanent  muscular  expression,  through  persistent  development, 
by  means  of  proper  gymnastic  exercises. 

These  exercises  are  neither  complicated  nor  costly.  They  are 
within  the  means  of  all  patients  and  the  scope  of  every  physician 
and  gymnasium  teacher.  Remember  that  braces  and  corsets  have 
no  place  in  the  treatment  of  postural  scoliosis.  The  best  brace  is 
a  well-developed  muscle. 

The  scheme  of  gymnastics  here  outlined  is  merely  suggestive, 
it  must  be  modified  to  meet  the  needs  of  the  individual  case.  Dur- 
ing the  first  month  the  daily  drill  should  be  no  longer  than  a  half 
hour.  Afterwards  it  may  gradually  be  increased  to  one  hour. 
Whatever  exercise  is  prescribed,  its  efficacy  will  be  in  proportion  to 
its  regularity  and  the  demands  which  it  makes  upon  sunshine  and 
fresh  air. 

Suggestive  Exercises. 

(a)  Proper  posture,  best   inculcated   by  teaching  the   military 
position,  and  by  using  some  modification  of  the  "setting-up"  drill 
in  the  military  school. 

(b)  Deep  breathing  develops  the  chest,  promotes  flexibility,  and 
increases  muscular  nutrition. 

(c)  Stretching  exercises,  such  as  are   obtained  by  hanging  on 
rings  or  bars,  will  have  an  excellent  effect  in  stretching  and  straight- 
ening the  column. 

(d)  Dumb-bell  exercises  are   highly  recommended,   not   merely 
for  developing  the  muscles  of  the  trunk,  but  to  cultivate  all  the 
muscles  of  the  body  and  thus  attain  a  condition  of  perfect  muscular 
coordination.     Techner's  system  of  exercises  with  light  dumb-bells, 
as  described  in  the  Annals  of  Surgery,  August,  1895,  is  an  excellent 
guide. 

(e)  Swimming  is    an   excellent   exercise   for   straightening   the 
vertebral  column  and  at  the  same  time  develops  the  chest  by  the 
enforced  deep  breathing.     These  exercises  should  be  continued  for 


ABNORMAL    POSITIONS    OF    SPINAL    COLUMN        415 

several  months  and  the  condition  of  the  spine  regularly  inspected 
and  recorded. 

Treatment  of  Structural  Scoliosis. — It  must  be  remembered  that 
in  these  cases  a  permanent  change  has  taken  place  in  the  spine  and 
its  soft  parts,  and  to  restore  flexibility  and  an  improved  position  is 
a  problem  which  requires  the  resources  of  an  orthopedic  clinic  and 
the  supervision  of  an  orthopedic  surgeon. 

The  methods  employed  have  for  their  aim  reduction  of  the  de- 
formity and  retention  of  the  corrected  position  until  permanent  re- 
covery is  obtained  by  building  a  "muscular  splint"  through  proper 
gymnastic  exercises.  Reduction  of  the  deformity  is  accomplished 
by  means  of: 

(a)  Gymnastic  exercises  which  bend  back  the  scoliotic  part  of 
the  spinal  column,  stretching  the  shortened  soft  parts  of  the  concave 
side  and  strengthening  the  overstretched  erector  spinse  of  the  con- 
vex side.     For  this  purpose  the  side-bending  exercises  are  useful. 

(b)  Corrective    apparatus.      Numerous    appliances    for   correct- 
ing scoliosis  have  been  devised,  some  of  which  are  very  complicated 
and  expensive.     Such  apparatus  is  intended  to  reduce  the  deformity 
and  strengthen  the  muscles  on  which  the  improved  position  relies 
for   support.      This   apparatus  is   available   only  in  the  orthopedic 
clinic  and  under  the  direction  of  the  orthopedic  surgeon. 

(c)  Passive  stretching.      Suspension  by  means   of  Sayre's   ap- 
paratus straightens  the  spine  and  reduces  both  the  curvature  and 
the  rotation.     The  results,  however,  are  futile  unless  the  advantage 
gained  is  secured  by  proper  muscular  support. 

(d)  Plaster  jackets  and  corsets.     It  must  be  remembered  that 
the  corrective  action  of  the  corset  is  slight;   its  function  is  solely 
to  retain  the  improved  position;  hence,  it  is  a  temporary  expedient 
to  be  used  only  while  an  efficient  musculature  is  being  developed, 
i.  e.,  between  the  exercise  periods  when  the  muscular  power  is  not 
sufficient  to  prevent  a  further  sagging  of  the  trunk  toward  the  con- 
vex side. 

It  is  also  indicated  when  intercostal  neuralgia  is  present.  The 
fitting  and  prescribing  of  these  corsets  should  be  left  to  the  ortho- 
pedic surgeon.  The  important  point  to  remember  is  that  there  is 


446  TUBERCULOSIS  OF  THE  SPINE 

nothing  curative  about  a  corset,  it  is  simply  a  temporary  splint,  and 
that  the  corset  without  exercise  is  futile. 

Rachitic  Scoliosis. — In  rachitic  scoliosis,  occurring  most  fre- 
quently from  the  fifth  to  the  tenth  year,  the  importance  of  general 
treatment  to  improve  the  body's  building  material  is  quite  evident. 
Again,  in  very  young  children,  we  cannot  count  on  the  efficacy  of 
gymnastics,  hence  the  most  efficient  means  is  prolonged  rest  on  a 
Bradford  and  Lovett  frame. 


CHAPTEE  LIV 

TUBERCULOSIS    OF    THE    SPINE 
(Pott's  Disease) 

Clinical  Picture. — Tuberculosis  of  the  spine  presents  the  same 
pathological  process  as  tuberculosis  of  bone  in  other  regions.  We 
see  here  the  same  orderly  pathological  events  which  in  an  uninter- 
rupted march  present  successively  a  typical  picture,  viz. :  the  forma- 
tion of  typical  tubercle,  typical  granulation  tissue,  typical  caseation, 
suppuration,  and  fistulization. 

The  clinical  picture  varies  because  of  the  peculiar  anatomical 
structure  and  relations  of  the  spine.  It  is  therefore  necessary  to 
grasp  certain  fundamental  structural  facts  concerning  the  spine  to 
clearly  comprehend  the  details  of  the  phenomena  which  the  tubercu- 
lous process  here  presents. 

Clinically  the  spine  is  a  flexible  bony  tube  which  lodges  the 
spinal  cord.  Furthermore,  this  flexible  bony  tube  is  composed  of 
a  number  of  superimposed  vertebral  segments,  each  articulating 
with  the  other  through  a  distinct  joint  and  all  bound  firmly  together 
by  strong  ligaments.  Though  little  movement  is  permitted  be- 
tween any  two  vertebra  (the  atlas  and  axis  excepted),  yet  the  col- 
lective motion  between  them  all  is  considerable.  Finally,  the  spine 
supports  and  connects  the  three  important  cavities  of  the  body:  the 
cranial,  the  thoracic,  and  the  abdominopelvic. 


CLINICAL    PICTURE  447 

It  must  be  also  noted  that  the  structure  of  the  individual  verte- 
brae plays  an  important  part  in  tuberculous  pathology.  A  vertebra 
consists  of  a  body  composed  of  spongy  bone,  and  an  arch  consisting 
of  several  processes  which  are  largely  composed  of  compact  tissue, 
and  connected  with  each  vertebra  are  four  joints  with  synovial 
cavities.  It  is  evident  that  the  spongy  vertebral  body  is  the  fertile 
fi~ld  for  tubercular  proliferation,  and  the  multiple  joints  are  gate- 
ways for  its  dissemination.  In  speaking  of  Pott's  disease,  there- 
fore, we  refer  to  tuberculosis  of  the  bodies  of  the  vertebrae. 

Pott's  disease  is  frequently  found  in  childhood,  specially  from 
the  second  to.  the  fifth  years — just  the  time  when  the  vertebrae  are 
assuming  their  weight-bearing  function.  Furthermore,  Spitzy 
shows  that  the  vertebra?  most  used  are  the  vertebras  most  frequently 
affected — in  small  children,  the  lower  thoracic  vertebrae  are  chiefly 
affected  because  in  the  kyphosis  of  sitting  they  are  most  depressed 
and  pushed  out;  in  adults,  the  lumbar  vertebras,  because  they  carry 
the  most  weight.  Rarely  are  the  cervical  vertebrae  attacked  in 
children. 

The  tuberculous  process  spreads  through  the  body  of  the  verte- 
bra in  a  characteristic  manner,  the  granulation  tissue  going  on  to 
caseation  and  often  suppuration.  The  intervertebral  fibrocartilag- 
inous  discs  are  destroyed  and  the  next  vertebra  invaded.  Thus, 
while  the  weight-bearing  bodies  are  destroyed,  the  articular  pro- 
cesses behind  remain  intact,  but  the  solidity  of  the  spinal  column 
is  undermined,  finally  yields  to  the  superimposed  weight,  and  col- 
lapses, forming  a  posterior  angulation  known  as  kyphosis  (Fig. 
163).  When  a  single  vertebra  is  affected  the  kyphosis  is  angular; 
when  several  vertebrae  are  involved  the  protrusion  is  more  or  less 
curved.  When  the  lateral  portion  of  a  body  is  affected  and  gives 
way  there  will  occur  a  lateral  tilt  (scoliosis). 

Hence  the  first  characteristic  of  Pott's  disease  is  deformity  of 
the  spine  (hump-back). 

But  the  primary  deformity  is  followed  by  secondary  compen- 
satory curves  which  may  entirely  change  the  normal  contour.  Thus 
an  angular  deformity  in  the  lumbar  spine  will  be  followed  by  a 
lordosis  of  the  dorsal  vertebrae;  a  deformity  of  the  cervical  column 


448 


TUBERCULOSIS   OF  THE  SPINE 


will  modify  the  normal  kyphosis  of  the  dorsal  column.  Thus  the 
deformity  of  Pott's  disease  may  so  modify  the  normal  curves  of 
the  spine  that  they  are  reversed.  Note  again  that  the  spine  sup- 
ports and  connects  the  three  important  cavities  of  the  body:  the 
cranial,  the  thoracic,  and  the  abdominopelvic.  It  must  be  evident 
that  a  deformity  in  the  dorsal  column  will  seriously  affect  the  thorax 
and  its  viscera.  Thus  the  chest  is  shortened  and  its  depth  in- 
creased (pigeon-breast).  Some- 
times the  lower  border  of  the  ribs 
is  pressed  against  the  iliac  crests. 
It  is  evident  that  compression  of 
the  thoracic  contents  interferes 
with  proper  oxygenation  of  the 
blood  and  seriously  compromises 
proper  nutrition.  Besides  this  it 
is  evident  that  the  abdominal  vis- 
cera are  also  compressed  and  dis- 
placed by  the  deformed  thorax. 
The  further  progress  of  the  dis- 
ease is  marked  by  the  appear- 
ance of  abscesses,  the  character- 
istic of  which  is  to  point  in  a 
region  far  removed  from  their 
origin. 

The  progress  of  the  abscess 
depends  upon  gravity,  and  the 
disposition  of  the  aponeurosis, 
since  it  burrows  along  the  fascial  planes  in  the  path  of  least  re- 
sistance. 

In  the  cervical  region  the  pus  may  burrow  backward  and  appear 
under  the  skin,  but  as  a  rule  it  pushes  forward  and  forms  a  retro- 
pharyngeal  abscess;  sometimes  it  burrows  beneath  the  dee])  fascia, 
compressing  the  trachea  and  esophagus,  and  invades  the  medi- 
astinum; or  it  may  pass  into  the  posterior  mediastinum  along  the 
great  vessels  and  into  the  thigh. 

In  the  dorsal  region  the  pus  may  break  through  the  pleura  into 


FIG.  163. — KYPHOSIS  OF  POTT'S  DISEASE. 


SYMPTOMS 

the  lung;  or  it  may  burrow  along  the  intercostal  spaces  and  appear 
on  the  anterior  surface  of  the  chest ;  or  it  may  travel  down  in  front 
of  the  bodies  of  the  vertebrae  and,  passing  beneath  the  internal 
arcuate  ligament,  enter  the  sheath  of  the  psoas  muscle,  thence  to 
the  iliac  fossae,  and  pass  beneath  Poupart's  ligament;  or  it  may 
descend  into  the  pelvis,  pass  through  the  great  sacrosciatic  foramen, 
and  point  on  the  back  of  the  thigh. 

In  the  lumbar  region  the  pus  usually  follows  the  course  of  the 
psoas  muscle,  descends  to  the  iliac  fossa,  passes  beneath  Poupart's 
ligament,  and  reaches  the  thigh  just  below  the  groin,  to  the  outer 
side  of  the  femoral  vessels;  or  it  may  make  its  way  into  the  ischio- 
rectal  fossa  and  form  a  perirectal  abscess. 

Paralysis. — Since  the  spine  is  a  flexible  bony  tube  which  lodges 
the  spinal  cord,  it  is  evident  that  the  cord  may  sometimes  become 
involved  by  extension  of  the  inflammatory  process  or  by  direct 
pressure  of  diseased  bone.  The  causes  of  the  compression  vary.  It 
may  be  an  inflammatory  thickening  of  the  dura;  or  the  granula- 
tion masses  may  invade  the  spinal  canal.  Sometimes  the  canal  is 
narrowed  by  ,an  encroaching  abscess  or  sequestrum.  Rarely  is  the 
compression  due  to  the  angular  deformity.  Whatever  the  cause  of 
the  compression  there  results  a  lesion  of  that  part  of  the  cord  distal 
to  the  pressure  and  often  there  remains  a  sclerosis  with  secondary 
ascending  and  descending  degenerations. 

Symptoms. — It  is  evident  from  the  foregoing  pathology  that  the. 
three  conspicuous  symptoms  of  Pott's  disease  are:  deformity  of  the 
spine,  abscess  of  spinal  origin,  and  paralysis ;  yet  none  of  these  are 
early  symptoms  and  the  latter  is  inconstant  or  absent;  hence  they 
cannot  be  considered  in  the  early  diagnosis  which  is  so  essential  in 
arresting  the  progress  of  the  disease  and  obtaining  a  cure  without 
deformity. 

The  disease  must  be  recognized  not  by  the  major,  but  by  the 
minor  symptoms.  The  early  symptoms  are  the  result  of  disturb- 
ance of  the  function  of  the  spine.  The  normal  mobility  of  the  spine 
is  arrested  and  the  spine  is  immobilized  by  tension  of  the  muscles, 
hence  the: 

Symptoms  of  Attitude. — These  are  the  result  of  nature's  effort 


450  TUBERCULOSIS  OF  THE  SPINE 

to  form  a  muscular  splint  by  which  the  spine  is  put  at  rest.  Hence 
muscular  spasm  causing  rigidity  of  the  spine  is  one  of  the  earliest 
and  most  characteristic  symptoms.  !Note,  therefore,  that  these 
patients  make  every  effort  to  limit  movement  in  the  spine;  there  is 
no  desire  for  activity;  the  whole  attitude  is  one  of  spinal  rigidity 
and  anxious  care  to  protect  the  diseased  part.  This  is  observed  in 
the  peculiar  gait  which  is  characterized  by  the  guarded  manner  in 
which  the  patient  walks,  the  feet  touching  the  ground  with  great 
care,  the  weight  being  borne  upon  the  toes.  In  sitting  the  patient 
makes  an  effort  to  support  the  trunk  by  grasping  the  seat  or  the  arm 
of  the  chair. 

In  standing  the  nearest  objects  are  seized  for  support;  and  if 
the  child  is  asked  to  pick  up  something  from  the  floor  the  back  is 
held  rigid  while  the  hip  and  knee  joints  are  bent;  when  the  pelvis 
is  sufficiently  lowered  for  the  child  to  seize  the  object  the  erect 
posture  is  carefully  resumed  by  placing  the  hands  on  the  anterior 
surface  of  the  thigh.  (Fig.  164.) 

In  cervical  disease  there  may  be  rigidity  resembling  torticollis, 
and  the  head  is  often  supported  by  the  hands  while  the  elbows  rest 
upon  something. 

In  dorsal  disease  there  is  an  appearance  of  abnormally  square 
shoulders.  These  children  do  not  want  to  be  handled  or  seized  by 
others — they  avoid  everything  that  can  cause  movement  in  the 
distressed  vertebral  joints. 

Pain. — The  pain  of  Pott's  disease  is  due  to  irritation  of  the 
roots  of  the  spinal  nerves  and  is  usually  referred  to  the  peripheral 
ends  of  the  nerves  in  their  area  of  distribution.  Thus  occipital 
neuralgia,  pain  in  the  chest  and  abdomen,  the  "belly-ache"  of  dorsal 
caries  are  frequent  sources  of  diagnostic  errors. 

There  may  also  be  pain  over  the  affected  vertebrae,  provoked  by 
direct  pressure  or  by  percussion.  As  Kirmisson  observes,  "Method- 
ical pressure  on  the  spinal  processes  sometimes  gives  no  results, 
while  a  percussion  exercised  on  the  same  processes  gives  pain.  This 
is  quite  easy  to  understand,  for  it  is  not  the  spinal  process  itself 
which  is  affected,  but  rather  the  corresponding  vertebral  body. 
Thus  a  sharp  percussion  may  be  sufficient  to  give  a  shock  to  the 


SYMPTOMS 


451 


focus  of  the  disease,  while  pressure  alone  is  not  enough  to  cause  it 
The  use  of  both  these  means  of  examination  must  therefore  never 
be  omitted." 

Finally  it  may  be  said  that  early  pain  of  Pott's  disease  is  a 
referred  pain.      This   pain   is  lessened   in   repose,   exaggerated  by 


FIG.  164. — CHARACTERISTIC  ATTITUDE  OF  THE  PATIENT  IN 
PICKING  UP  AN  OBJECT  FROM  THE  GROUND — SHOWING 
THE  RIGIDITY  OF  THE  SPINE  IN  POTT'  DISEASE.  (Spitzy.) 

fatigue,  and  augmented  by  pressure  or  percussion  over  the  spinal 
processes. 

Deformity. — In  advanced  Pott's  disease  the  most  characteristic 
symptom  is  the  deformity  or  angulation  of  the  vertebral  column 
(humpback)  caused  by  the  collapse  of  the  affected  vertebral  bodies. 
The  hump  is  most  accentuated  in  the  dorsal  region,  where  there  is  a 
normal  backward  convexity,  and  less  pronounced  in  the  cervical  and 
lumbar  regions.  In  some  cases  the  destruction  of  the  vertebral 
bodies  is  so  irregular  that  a  lateral  deviation  is  produced — when 


\z  \.'  \  ki-i  r  i   •  iv1  <- 


452  TUBERCULOSIS  OF  THE   SPINE 

this  occurs  in  the  early  stage  of  the  disease,  before  the  angular  de- 
formity appears,  it  may  easily  be  mistaken  for  a  scoliosis. 

Abscesses. — The  tendency  of  these  abscesses  to  gravitate  to  a 
region  far  removed  from  their  origin  has  been  noted  in  the  pathol- 
ogy. It  is  obvious  that  the  symptoms  of  these  abscesses  vary  with 
the  region  in  which  they  localize.  Thus  cervical  abscesses  will  give 
symptoms  of  difficult  respiration  and  deglutition ;  others  will  present 
pressure  symptoms  in  the  mediastinum,  causing  dyspnea  and 
cyanosis ;  pressure  on  nerves,  causing  pain  in  the  lower  extremities ; 
psoas  contraction,  causing  flexion,  abduction,  and  external  rotation 
of  the  thigh,  which  simulate  hip  disease. 

The  rupture  of  these  abscesses  is  followed  by  discharging  fistulas 
which,  in  the  course  of  years,  find  a  fatal  termination  in  amyloid 
degeneration  of  the  viscera. 

Pott's  paralysis  is  usually  a  paralysis  of  the  lower  limbs,  due 
to  compression  of  the  cord  as  described  in  the  pathology.  It  is  well 
to  note  that  this  nervous  phenomenon  may  be  one  of  the  earliest 
symptoms  before  the  appearance  of  the  deformity.  The  motor 
nerves  are  affected  long  before  the  sensory  nerve  paths  are  damaged. 

The  patella  reflex  is  increased,  ankle  clonus  is  present.  Long 
after  motor  paresis  is  established  there  follows  paralysis  of  the 
bladder  and  rectum,  causing  incontinence  of  urine  and  feces. 

Examination  of  patient  is  extremely  important  since  a  diag- 
nosis cannot  be  made  without  an  observation  of  the  objective  symp- 
toms. For  this  purpose  the  child  should  be  stripped  naked  and  the 
symptoms  of  attitude  carefully  noted.  Observe  the  patient's  atti- 
tude in  walking,  standing,  sitting  down,  and  getting  up.  Ask  the 
child  to  pick  up  some  object  from  the  floor.  These  movements  will 
bring  out  the  evidence  of  spinal  rigidity. 

Have  the  child  lie  on  his  belly  on  a  table  and  try  to  hyper- 
extend  the  spine  by  lifting  the  legs  from  the  table.  Normally  the 
spine  will  be  flexed  by  this  movement  (Fig.  165)  ;  in  Pott's  disease 
the  spine  is  held  rigid  and  the  contracted  muscles  cause  it  to  be  lifted 
in  one  piece.  (Fig.  166.) 

Carefully  note  the  movements  of  the  head ;  any  limitation  of 
them  should  cause  suspicion.  If  deformity  is  present  a  permanent 

ft  3  J  J r, 


DIAGNOSIS 


453 


FIG.  165. — METHOD  OF  DEMONSTRATING  NORMAL 
FLEXIBILITY  OF  THE  SPINE. 


record  should  be  made 
for  future  reference  by 
placing  the  child  on  his 
abdomen  and  molding  a 
lead  strip  to  the  spine. 
The  outline  is  traced  on 
cardboard,  cut  out,  and 
refitted  to  the  spine. 

Diagnosis.  — E  a  r  1  y 
diagnosis  is  essential  for 
the  prevention  of  defor- 
mity and  the  serious  se- 
quela which  mark  its 
later  stages.  There  is 
no  disease  whose  mim- 
icry of  visceral,  disor- 
ders covers  so  wide  a  range  or  offers  so  fertile  a  field  for  diagnostic 
errors.  As  Willard  observes,  "The  infection  is  frequently  treated  for 
rheumatism  until  the  kyphosis  appears;  for  pharyngitis,  bronchitis, 
pneumonia,  pleurisy,  gastritis,  appendicitis,  nephritis  and  cystitis." 

The  early  diagnosis 
must  be  made  by  mus- 
cular spasm  and  reflex 
pain.  The  X-ray  will  be 
serviceable  only  in  diag- 
nosing disease  of  the 
cervical  vertebrae.  The 
tuberculin  test  may  be  a 
valuable  diagnostic  ad- 
junct. An  excellent  rule 
to  follow  is:  when  in 
doubt  give  the  patient 
the  benefit  of  the  doubt 
b  y  immobilizing  the 
spine.  Such  a  procedure 


FIG.    166. — METHOD    OF    DEMONSTRATING  RIGIDITY 
OF  THE  SPINE. 


will  cause  no  regret. 


454  TUBERCULOSIS  OF  THE  SPINE 

Differential  Diagnosis. — It  is  evident  that  when  the  disease  is  well 
advanced  there  is  no  difficulty  in  diagnosis.  But  at  the  onset,  with 
the  multiplicity  of  referred  pains,  and  the  wide  range  of  their 
activity,  there  seems  to  be  offered  an  extensive  field  for  differential 
diagnosis.  Yet  if  the  chronicity  of  the  tuberculous  process  and  its 
accompanying  malaise  be  given  due  weight;  if  its  expression  in  the 
spine,  invariably  manifest  by  muscular  spasm  and  spinal  rigidity, 
be  properly  considered,  many  of  the  disorders  which  it  simulates 
will  be  promptly  eliminated,  and  the  number  of  pathological  con- 
ditions with  which  it  is  likely  to  be  confounded  will  be  greatly 
reduced. 

(a)  Lateral  Curvature. — If  the  Pott's  deformity  is  not  median 
but  lateral  a  scoliosis  may  be  suggested.     But  scoliosis  has  none  of 
the  characteristics  of  a  disease.     It  is  a  deformity  characterized  not 
only  by  a  lateral  curve  but  by  a  certain  amount  of  rotation  of  the 
vertebrae  which  gives  prominence  to  the  ribs  on  one  side  and  makes 
the  shoulder  of  one  side  higher ;  but  there  are  no  muscular  rigidity, 
no  pain,  no  abscess,  no  paralyses. 

(b)  Rachitic  Jcyphosis  never  presents  the  angular  deformity  of 
Pott's  disease.     There  is  a  long  posterior  curve  which  can  be  re- 
duced by  manipulation;  there  is  no  muscular  rigidity,   and  other 
signs  of  rachitis  are  usually  present. 

(c)  Wry-neck. — When    cervical    disease    is    present   there    may 
exist  a  sideward  rotation  of  the  head  that  causes  a  torticollis  posi- 
tion.     Yet  in  wry-neck  complete  painful   fixation  is   absent,   only 
the  opposite  movement  is  hindered.     In  cervical  Pott's  disease  every 
movement  is  hindered.    (See  Congenital  Torticollis  or  Wry-neck,  pp. 
396-397.) 

(d)  Hip  Disease. — In  the  psoas   contraction  of  Pott's   disease 
the  movements   of  extension,    adduction,    and   inward   rotation  are 
limited;  in  hip  disease  the  hip  is  fixed  and  motion  is  limited  in  all 
directions.     Besides,  absence  of  pain  in  the  hip  joint  and  muscular 
rigidity  of  the  spine  will  clear  up  the  diagnosis. 

(e)  Sarcoma  presents  symptoms  that  closely  resemble  tubercu- 
losis of  the  spine.     Sarcoma  is  extremely  rare,  rapidly  progressive, 
is   marked   by   a   more   diffused   and   irregular   deformity,   and    is 


TKEATMENT  455 

accompanied  by  agonizing  pain  due  to  pressure  upon  the  posterior 
nerve  roots,  which  is  not  relieved  by  rest. 

(f)  Traumatic  spondylitis  may  be  followed  by  an  angular  de- 
formity which  closely  resembles  Pott's  disease.  The  characteristics 
of  this  disease  have  been  described  by  Kiimmel.  It  is  a  post- 
traumatic  condition  in  which  the  symptoms  appear  long  after  the 
original  injury,  and  is  marked  by  pain  along  the  peripheral  nerves, 
sometimes  paralyses,  and  the  gradual  development  of  an  angular 
deformity  which  simulates  the  deformity  of  tuberculous  spine.  It 
is  evident  that  such  a  train  of  symptoms  may  make  diagnosis  ex- 
tremely difficult.  The  history  of  the  case,  the  absence  of  muscular 
spasm  and  abscess  formation,  and  the  greater  amount  of  tender- 
ness will  exclude  Pott's  disease. 

Prognosis. — Pott's  disease  runs  an  extremely  chronic  course. 
Prognosis  depends  not  only  upon  the  promptness  and  efficacy  of  the 
treatment  but  upon  the  vital  asset  of  the  patient's  tissues.  When 
deformity  is  present,  it  remains  permanent  and  the  ultimate  cure 
of  the  disease  is  at  the  price  of  a  hump-back.  The  presence  of 
paralysis  does  not  necessarily  affect  the  prognosis  unfavorably. 
With  the  subsidence  of  the  disease  the  pressure  effects  may  abate 
and  the  cord  be  restored  to  its  normal  function. 

It  is  well  to  remember  that  of  all  the  tuberculous  affections  of 
bones  or  joints  Pott's  disease  takes  the  longest  to  cure.  It  is  im- 
possible to  definitely  state  the  length  of  time  over  which  the  treat- 
ment must  extend.  In  cervical  disease  not  less  than  two  years,  in 
dorsal  and  lumbar  affections  four  or  five  years,  or  more. 

Treatment. — Here,  as  in  all  tuberculous  processes,  we  are  treat- 
ing the  local  expression  of  a  general  condition;  hence  it  is  of  para- 
mount importance  to  so  improve  the  tissues  by  general  hygienic 
measures  that  the  tubercle  bacilli  will  cease  to  thrive. 

GENERAL  TREATMENT  consists  in  proper  nutrition,  unlimited 
sunshine  and  fresh  air. 

LOCALLY,  the  indications  in  Pott's  disease  call  for  rest,  which 
implies  the  removal  of  all  weight  and  as  complete  immobilization 
of  the  spine  as  possible.  This  simple  principle  of  rest  persisted  in 
for  many  years  offers  the  only  hope  for  a  favorable  result.  Com- 


45G  TUBERCULOSIS  OF  THE  SPINE 

plete  rest  for  the  spine  can  best  be  secured  by  recumbency  in  bed, 
which  relieves  the  superimposed  weight,  and  by  some  fixation  ap- 
paratus which  completely  immobilizes  the  spine. 

It  is  evident  that  this  treatment  cannot  be  satisfactorily  carried 
on  in  an  out-patient  clinic.  Unless  the  social  position  of  the  patient 
permits  this  treatment  being  satisfactorily  carried  out  at  home,  the 
patient  should  be  treated  in  a  suitable  institution,  otherwise  the 
end  results  cannot  be  the  best  for  life  and  deformity. 


GENERAL    RULES 

(1)  Absolute  recumbency — when  the  lesion  is  in  an  acute  stage; 
or  in  the  presence  of  abscess  or  paraplegia ;   and  continued  until 
all  inflammatory  phenomena  have  subsided.      In  general  the  time 
required  is  from  twelve  to  eighteen  months. 

(2)  Ambulatory   treatment — when   on  careful  examination  the 
patient  is  free   from  pain   and   all  inflammatory   phenomena,    and 
the  formation  of  ankylosis  at  the  seat  of  the  lesion  is  well  advanced. 
The  patient  may  then  be  allowed  to  assume  the  upright  position 
after  the  application  of  some  fixation  splint  for  spinal  support. 

(1)  Treatment  by  recumbency  is  most  satisfactorily  accom- 
plished by  the  use  of  the  Whitman-Bradford  canvas-covered  gas-pipe 
frame  (Fig.  167),  which  is  described  by  Whitman  as  follows:  "It  is 
made  of  ordinary  galvanized  gas-pipe  or  steel  tubing  of  a  small  di- 
ameter. It  should  be  about  four  inches  longer  than  the  child,  and 
about  four-fifths  as  wide,  the  lateral  bars  corresponding  to  the  articu- 
lar surfaces  of  the  four  extremities  with  the  trunk.  *  '  The  cover 
should  be  of  strong  canvas  suitably  protected  in  the  center  by  rubber 
cloth.  This  is  applied  and  drawn  tight  by  means  of  corset  lacings 
and  straps.  Upon  this  two  thick  pads  of  felt  are  sewed;  these 
should  be  about  seven  inches  in  length  and  about  an  inch  in  thick- 
ness, placed  on  either  side  of  the  spinous  processes  at  the  seat  of 
the  disease,  thus  protecting  them  from  pressure,  fixing  the  parts 
more  firmly  and  increasing  the  leverage  of  the  apparatus. 


TREATMENT  457 

"The  child,  wearing  only  an  undershirt,  stockings,  and  diaper,  is 
placed  upon  the  frame  and  is  fixed  there  usually  by  a  front  piece 
or  apron  similar  to  that  used  with  the  spinal  brace.  As  soon  as 
the  patient  has  become  accustomed  to  the  restraint  one  begins  to 
over-extend  the  spine  by  bending  the  bars  from  time  to  time,  with 
the  aim  of  actually  separating  the  diseased  vertebral  bodies  and 
obliterating  all  the  physiological  curves  of  the  spine,  so  that  the 
body  shall  be  finally  bent  backward  to  form  the  segment  of  a  circle. 
The  greatest  convexity  is  at  the  seat  of  the  disease,  and  as  the  head 
and  lower  extremities  are  on  a  much  lower  level  an  element  of 
gravity  traction  is  present  in  some  instances,  while  the  support 
of  the  spine,  as  a  whole,  is  much  more  comprehensive  than  when 


FIG.  167. — THE  WHITMAN-BRADFORD  FRAME.  (After  Whitman.) 

the  body  lies  upon  a  plane  surface."  (Whitman's  Orthopedic 
Surgery. ) 

The  patient  is  kept  continuously  recumbent.  The  skin  of  the 
back  is  kept  scrupulously  clean  by  turning  the  child  and  bathing 
the  back  daily  with  dilute  alcohol,  and  dusting  with  powder.  The 
urine  and  feces  are  received  in  a  bed-pan. 

The  use  of  the  canvas-covered  frame  overcomes  the  principal 
objection  to  the  recumbent  treatment,  since  it  offers  an  easy  method 
of  transportation,  and  the  patient  can  thus  receive  the  benefits  of 
being  kept  almost  continuously  out-of-doors. 

To  this  bed  frame  can  be  easily  attached  traction  for  the  head 
when  the  disease  is  in  the  cervical  region,  and  in  cases  of  paralysis 
traction  on  both  legs  may  be  added. 

The  deformity  is  reduced  gradually  and  without  pain  by  the 
use  of  the  felt  pads  on  each  side  of  the  diseased  vertebral  spines, 


458 


TUBERCULOSIS  OF  THE  SPINE 


and  the  spine  is  gradually  suporextended  backward  and  the  pressure 
on  the  diseased  vertebral  bodies  relieved  by  the  progressive  arching 
of  the  gas-pipe  frame  (Willard). 

(2)  Ambulatory  treatment  may  be  safely  begun  three  months 
after  the  cessation  of  all  acute  symptoms.  The  upright  position, 
however,  must  not  be  assumed  without  some  form  of  mechanical 

support  to  the  spine.  This  sup- 
port to  the  weakened  spine  may  be 
furnished  by  plaster  jackets  or 
steel  braces. 

Spitzy's  suggestion  to  permit 
the  patient  to  gradually  resume 
the  upright  position  is  worthy  of 
commendation.  After  a  plaster 
jacket  is  applied  he  allows  the  pa- 
tient out  of  bed,  but  not  to  walk. 
The  child  is  permitted  only  to 
crawl,  so  that  the  vertebral  column 
may  still  be  free  from  weight. 
After  this  form  of  locomotion  has 
been  practised  for  a  few  months 
the  child  is  allowed  to  walk. 

For  after-treatment  a  steel 
brace  similar  to  the  Taylor  appa- 
ratus is  highly  efficient.  (Fig. 
168).  By  this  means  the  spine  is 
splinted  from  pelvis  to  shoulders 
by  two  steel  uprights  on  either  side  of  the  vertebral  spines,  joined 
above  and  below  by  cross-pieces  and  held  in  position  by  shoulder 
straps  and  by  a  canvas  apron  extending  from  the  top  of  the  sternum 
to  the  pubis.  Perineal  straps  may  be  added  if  there  is  a 
tendency  for  the  brace  to  slip  upward.  The  brace  should  be 
worn  day  and  night.  Great  care  must  be  observed  to  prevent 
excoriation  of  the  skin  by,  first,  having  the  brace  accurately  fitted 
and  properly  padded;  and,  second,  by  removing  the  splint  daily 
while  the  child  is  lying  down  so  that  the  skin  may  be  carefully 


HI  f . 


168. — THE    TAYLOR    BRACE    FOB 
SUPPORTING  THE  SPINE. 


TREATMENT 


459 


bathed  and  powdered.  When  the  disease  is  in  the  cervical  or  upper 
dorsal  region  a  head  support  should  be  used — either  a  Sayre's  jury- 
mast  attached  to  the  plaster  jacket,  or  the  addition  of  an  oval  ring 
supported  on  a  post  attached  to  the  upper  part  of  the  Taylor  brace 
(Fig.  169). 

The  Application  of  Plaster  Jackets. — The  application  of  an 
efficient  plaster  jacket  is  an  art.  Hence,  the  efficiency  of  a  plaster 
jacket  depends  upon  the  skill 
with  which  it  is  applied.  An 
ill-fitting  plaster  jacket  is  worse 
than  useless,  for  it  only  adds  in- 
sult to  injury.  It  hides  without 
helping  the  defect,  and  thus  de- 
ceives both  physician  and  pa- 
tient. However  clearly  defined 
the  principles  of  the  plaster 
jacket,  or  the  details  of  its  ap- 
plication, what  give  it  worth 
are  the  judgment  and  skill  of 
the  surgeon  who  applies  it. 

The  aim  of  the  plaster  jacket 
is  to  act  not  only  as  a  splint  to 
the  spine  but  to  secure  fixation 
in  an  improved  position.  The 
old  method  of  applying  the  plas- 


FIG.  169. — SUPPORT  FOR  THE  HEAD  AT- 
TACHED TO  THE  UPPER  PABT  OF  THE 
TAYLOR  BRACE. 


ter  jacket  with  vertical  suspen- 
sion has  fostered  the  erroneous 
idea  that  suspension  pulled  the 
vertebra  apart,  and  the  support  of  the  jacket  prevented  the  vertebrae 
from  coming  in  contact.  The  whole  effect  of  vertical  suspension  is  to 
reduce  the  physiological  curves  without  affecting  the  kyphos.  Hence 
the  improved  position  is  more  readily  attained  by  applying  the 
jacket  while  the  patient  is  in  a  position  of  horizontal  suspension 
or  recumbency.  For  this  purpose  the  "hammock  frame"  of  Brad- 
ford and  Lovett  has  been  found  to  be  admirably  adapted  (Fig. 
170). 


460 


TUBERCULOSIS  OF  THE  SPINE 


Upon  this  the  patient  rests  face  downward,  the  arms  are  ex- 
tended, and  the  hands  grasp  the  frame  above.  The  roller  bandage 
is  passed  through  the  slits  in  the  canvas  on  each  side  and  includes 
the  canvas,  which  is  cut  away  after  the  bandage  is  completed. 


FIG.  170. — THE  "HAMMOCK  FRAME"  OF  BRADFORD  AND  LOVETT. 


(Fig.  171.)     The  principle  of  this  simple  apparatus  must  be  well 
understood  to  be  appreciated. 

It  is  well  summarized  by  Lovett  in  "Keen's  Surgery":     "The 


FIG.  171. — METHOD  OF  APPLYING  PLASTER  JACKET  IN  THE  BRADFORD-LOVETT  FRAME. 

(Ware.) 

cloth  is  fastened  to  a  rectangular  frame  of  gas-pipe,  at  one  end 
firmly,  and  at  the  other  by  means  of  a  rod  attached  to  the  other 
side  of  the  frame  fastened  to  a  screw  and  chain,  by  which  means 


TEEATMENT 


4G1 


the  hammock  can  be  made  either  tight  or  loose.  *  *  The  jacket 
is  then  applied  as  far  as  the  level  of  the  apex  of  the  deformity 
and  allowed  to  harden.  The  hammock  is  then  loosened,  hyper- 
extending  the  patient  and  straightening  the  upper  part  of  the  spine. 
This  is  carried  to  the  point  of  slight  discomfort  and  the  jacket 
completed.  In  this  way  a  hyperextension  is  obtained  directly  at 
the  seat  of  disease." 

The  Calot  jacket  is  one  of  the  most  effective  forms  of  ambu- 
latory support,  but,  contrary  to  the  author's  teaching,  it  is  difficult 
to  apply.  As  shown  in  Fig.  172,  it  is  essentially  a  plaster  jacket 
which  combines  fixation  of  the  neck  and  shoulders  with  that  of 
the  pelvis.  The  front  is  cut  away  and  a  window  is  cut  in  the  back 


FIG.  172. — THE  CALOT  JACKET  WITH  OPENING  OVER  KYPHOS  FOR  THE 
INSEBTION  OF  COTTON-PADS  TO  DIMINISH  THE  DEFORMITY.  (Ware.) 

over  the  kyphosis,  as  illustrated,  through  which  pads  of  cotton 
wadding  are  forced  and  held  in  place  by  adhesive  plaster.  The 
trunk  is  in  this  way  forced  forward  and  the  deformity  dimin- 
ished. 

This  treatment  of  the  kyphosis  is  repeated  at  intervals  of  two 
months. 

The  Application  of  Braces. — While  the  plaster  jacket  is  cheap 
and  readily  applied,  it  has  many  disadvantages  which  render  it 
inferior  to  the  brace.  After  a  time  the  plaster  jacket  becomes  loose 
and  ceases  to  be  an  accurate  or  adequate  support  to  the  diseased 
spine.  Besides  this,  it  is  hot  and  dirty  and  does  not  readily  permit 
inspection  of  the  back  or  adjustment  to  the  modified  shape  of  the 
spinal  column.  It  is  evident  that  these  objections  do  not  apply  to 
the  adjustable  brace,  which  in  many  cases  will  be  found  the  pref- 


462  TUBERCULOSIS  OF  THE  SPINE 

erable  form  of  support.  The  efficiency  of  the  brace  depends  upon 
the  accuracy  of  its  construction  and  the  skill  with  which  it  is  ad- 
justed. It  is  evident,  therefore,  that  the  construction  and  applica- 
tion of  the  brace  should  be  under  the  direction  of  an  orthopedic 
surgeon  specially  fitted  by  training  and  experience.  In  ordering  a 
brace  an  outline  of  the  spine  should  be  made  with  the  patient  lying 
prone.  This  is  done  with  a  pliable  metal  strip  laid  upon  the  spine 
and  accurately  fitted  to  its  curves  from  the  neck  to  the  sacrum. 
The  molded  metal  strip  is  carefully  transferred  and  laid  on  its 
side  upon  card-board  and  the  outline  traced  to  serve  as  a  guide  in 
the  construction  of  the  brace.  After  the  brace  is  completed  its 
accurate  adjustment  and  proper  fitting  require  the  skill  that  is 
acquired  only  by  experience. 

OPERATIVE  TREATMENT. — Dr.  Russell  A.  Hibbs  has  recently 
proposed  an  operation  for  Pott's  disease  which  aims  to  produce  "a 
fusion  of  the  posterior  aspects  of  the  vertebrae,  to  obliterate  motion 
of  the  vertebral  articulations  over  the  diseased  area,  and  to  relieve 
pressure  on  the  involved  bodies,  thereby  hastening  the  cure  and 
preventing  deformity."  The  author  proposes  to  accomplish  by 
operation  what  nature  attempts  to  do,  viz.,  to  eliminate  motion  of 
the  diseased  joints  by  an  extraordinary  bony  growth.  The  author 
describes  the  operation  as  follows:  "A  longitudinal  incision  is  made 
directly  over  the  spinous  processes  through  the  skin,  supraspinous 
ligament,  and  periosteum,  to  the  tips  of  the  spinous  processes.  The 
periosteum  is  split  over  both  the  upper  and  lower  borders  of  the 
spinous  processes  and  the  laminae,  and  stripped  from  them  to  the 
base  of  the  transverse  processes."  The  spinous  processes  are  partially 
fractured  and  used  for  bridging  the  gap  between  the  vertebne  (Fig. 
173). 

"The  lateral  walls  of  periosteum  and  of  the  split  supraspinous 
ligament  are  brought  together  over  these  processes  by  interrupted 
chromic  cat-gut  sutures.  The  skin  wound  is  closed  by  silk,  and  a 
steel  brace  applied,  with  the  space  between  the  uprights  increased 
somewhat  at  the  site  of  the  wound  so  as  not  to  make  pressure  upon 
it"  (Annals  of  Surgery,  May,  1912).  The  author  reports  a  num- 
ber of  cases  with  excellent  results. 


TREATMENT 


4(53 


TREATMENT  OF  COMPLICATIONS — Abscess. — It  has  already  been 
observed  that  the  characteristic  of  these  abscesses  is  to  point  in  a 
region  far  removed  from  their  origin.  It  is  obvious  that  the  super- 
ficial collection  of  pus  is  but  the  terminus  of  a  long  suppurating 
tract,  which  no  operation,  however  thorough,  can  cleanse,  and  which 
in  opening  becomes  the  gateway  of  secondary 
infection  and  possible  death. 

The  treatment  here,  as  in  all  tuberculous 
abscesses,  is  strictly  conservative.  Under  the 
expectant  treatment  many  of  these  abscesses 
disappear  spontaneously.  When  the  abscess 
approaches  the  surface  it  should  be  aspirated 
under  aseptic  precautions,  its  contents  re- 
moved by  suction,  and  injected  with  a  five 
per  cent*,  emulsion  of  iodoform  and  glycerin. 
This  is  repeated  as  often  as  the  pus  accumu- 
lates and  discontinued  when  the  fluid  with- 
drawn becomes  serous  in  character.  When 
the  abscess  becomes  acute  prompt  incision  is 
indicated. 

Retropharyngeal  abscess  demands  prompt 
evacuation  since  it  interferes  with  respira- 
tion and  deglutition,  and  if  it  discharges 
spontaneously  into  the  pharynx  it  may  give 
rise  to  asphyxia  and  septic  pneumonia. 
These  abscesses  may  be  evacuated  by  an  in- 
cision through  the  pharynx  (with  the  head 
hanging  low  to  prevent  the  pus  getting  into  the  larynx),  or,  better 
still,  by  an  incision  along  the  posterior  border  of  the  sternomastoid 
muscle  below  the  level  of  the  mastoid  process.  The  incision  is 
deepened  by  blunt  dissection  until  the  cavity  of  the  abscess  is 
reached. 

Pott's  Paraplegia. — The  treatment  of  the  paralysis  is  recumb- 
ency with  traction.  Internal  remedies,  electricity,  and  counter- 
irritation  are  of  little  value.  In  paralyses  resisting  all  conservative 
treatment,  where  the  indications  are  vital,  the  operation  of  laminec- 


FIG.  173. — LATERAL  VIEW 
OF  THE  TRANSPOSED 
S  P  i  N  o  u  s  PROCESSES. 
(Hibbs.) 


464  TUBERCULOSIS  OF  THE  SPINE 

tomy  may  be  contemplated.  The  operation,  however,  is  grave  and 
the  results  are  not  encouraging. 

Suboccipital  Pott's  Disease. — Under  this  term  is  included  tuber- 
culous inflammation  of  the  articulation  between  the  occipital  bone 
and  the  atlas  and  the  atlas  and  axis.  It  is  not  a  special  disease  of 
childhood,  but  is  frequently  observed  during  this  period.  It  is 
evident  that  the  gravity  of  this  disease  is  due  to  its  proximity  to 
the  medulla  and  the  tendency  to  spontaneous  dislocation,  causing 
sudden  death. 

The  pain  is  intense,  radiating  along  the  neck  and  toward  the 
shoulder;  it  is  increased  on  moving  the  head;  hence  these  patients 
hold  the  head  in  a  state  of  fixation,  support  the  head  with  the 
hands,  and  rather  than  rotate  the  head  they  turn  the  eyes  or  the 
whole  body,  while  the  head  is  immobilized  by  the  muscles. 

Should  abscess  form  it  may  point  at  the  back  of  the  pharynx, 
the  posterior  border  of  the  sternomastoid  muscle,  or  the  subclavian 
triangle.  The  treatment  is  recumbency  with  extension  during  the 
acute  stage.  Later  immobilization  by  an  efficient  head  brace  or  a 
Calot  support.  In  summing  up  the  treatment  of  Pott's  disease 
the  judicious  remarks  of  Bradford  and  Lovett  are  well  worth 
accentuating:  "The  proper  treatment  of  Pott's  disease  is  not  the 
application  of  any  method,  the  use  of  any  corset  or  brace,  but  the 
employment  of  such  means  as  are  efficient  for  carrying  out  the 
object  aimed  at."  '  *  *  "In  the  treatment  of  these  cases  the  sur- 
geon should  be  familiar  with  the  advantages  to  be  gained  by  all 
methods,  and  should  employ  each  as  the  case  demands,  and  for  such 
a  length  of  time  as  the  circumstances  of  the  case  may  require,  or 
combine  the  different  methods  as  may  be  advisable." 


TUBERCULOSIS   OF    THE   SACROILIAC   JOINT 

Tuberculosis  of  the  sacroiliac  joint  is  rarely  observed  in  chil- 
dren ;  it  may  be  secondary  to  Pott's  disease.  The  usual  tuberculous 
process  goes  on  to  abscess  formation,  which  is  often  the  first  symp- 
tom which  calls  attention  to  the  disease.  The  location  of  the  joint 


TREATMENT  465 

is  such  that  the  pus  may  find  its  way  to  remote  parts;  along  the 
psoas  muscle  to  the  iliac  fossa,  or  groin ;  through  the  sciatic  foramen 
to  the  buttock ;  or  along  the  sacrum  and  coccyx  to  the  rectum,  where 
it  may  appear  as  a  periproctitic  abscess. 

Symptoms. — Pain,  due  to  weight-bearing,  or  pressure  on  the 
sciatic  nerve.  Pain  may  be  provoked  by  deep  abdominal  pressure 
toward  the  sacroiliac  synchondrosis,  or  by  rectal  palpation;  or  by 
flexion  of  the  thigh  while  the  leg  is  extended.  Spitzy  regards  pain 
on  pressing  the  pelvic  bones  together  as  a  pathognomonic  sign  and 
in  conjunction  with  abscess  the  diagnosis  is  positive. 

There  is  discomfort  in  walking,  freedom  of  gait  is  lost,  short 
steps  are  taken  to  avoid  pelvic  motion,  and  the  patient  stands  with 
the  weight  thrown  toward  the  sound  side,  producing  a  lateral 
curvature. 

Diagnosis. — The  diagnosis  is  not  always  easy,  it  may  be  con- 
founded with  Pott's  disease  of  the  lumbar  spine  and  hip  disease. 
Attention  is  called  to  the  pathognomonic  sign  of  Spitzy — pain  on 
pressing  the  pelvic  bones  together.  An  X-ray  plate  will  be  the 
best  protection  against  mistakes. 

Prognosis  is  bad.  The  anatomical  conditions  are  such  that  ab- 
scess may  go  on  for  years,  invading  the  pelvis  and  consuming  the 
vital  resistance  of  the  child. 

Treatment  is  not  satisfactory.  The  most  that  can  be  done  is  to 
aspirate  the  abscess  formation  and  inject  with  iodoform  emulsion. 
Immobilize  the  pelvis  and  leg  of  affected  side  in  a  plaster  cast. 
Put  a  thick-sole  shoe  on  the  sound  side  and  let  the  patient  walk 
with  crutches.  Operation  in  children  is  scarcely  to  be  considered. 


SECTION  XII 
ABDOMEN  AND   PELVIS 
CHAPTER  LV 

CONGENITAL  AFFECTIONS  OF  THE  ABDOMEN 

Imperfect  development  of  the  anterior  abdominal  wall  may  re- 
sult in  the  absence  of  a  portion  of  the  wall,  so  that  the  viscera  are 
exposed  and  unprotected;  or  a  lack  of  union  in  the  median  line 
may  be  evidenced  by  a  congenital  hernia,  which  may  vary  from 
one  of  small  size  to  a  protrusion  containing  all  the  movable  viscera. 

The  highest  grade  of  malformation  presents  a  fissure  involving 
abdomen,  bladder,  and  intestine.  These  cases,  however,  are  not 
viable  or  operable  and  have  no  practical  interest  for  the  surgeon. 
Since  the  umbilicus  is  the  entrance  for  the  embryo's  nutrition  and 
the  means  of  communication  between  mother  and  child,  it  is  the 
part  that  is  closed  last,  and  is  a  special  center  for  congenital  defects. 

MECKEL'S  DIVERTICULUM 

Clinical  Anatomy. — Meckel's  diverticulum  represents  a  portion  of 
the  omphalomesenteric  duct  which  has  not  closed.  As  a  result  there 
remains  a  diverticulum  or  tube  similar  to  the  appendix,  which  is 
attached  to  the  ileum  in  the  vicinity  of  the  ileocecal  valve  (the 
distance  varies  from  several  inches  to  two  or  three  feet).  This 
diverticulum  may  give  rise  to  certain  conditions  of  great  practical 
interest  to  the  surgeon. 

1.  It  may  remain  attached  to  the  intestine  and  hang  freely  in 
the  abdominal  cavity  as  a  blind  diverticulum.  This  is  the  form  of 
diverticulum  described  by  Meckel,  attached  to  the  convex  free  bor- 

466 


MECKEL'S    DIVERTICULUM  467 

der  of  the  intestine  in  the  vicinity  of  the  ileocecal  valve.  (It  is 
rarely  attached  near  the  mesenteric  border.)  Its  length  varies  from 
one  to  three  inches  and  it  communicates  with  the  cavity  of  the  in- 
testine. It  is  evident  that  this  form  of  diverticulum  may  give  rise 
to  internal  strangulation  either  by  the  adhesion  of  its  tip  to  other 
loops  of  intestine  or  by  forming  adhesions  to  the  abdominal  wall. 
The  authors  have  successfully  operated  on  a  case  of  intestinal  obstruc- 
tion caused  by  a  diverticulum  adherent  to  the  abdominal  wall  about 
which  the  intestines  rotated,  forming  a  complete  volvulus. 

Even  when  the  diverticulum  hangs  free  in  the  abdominal  cavity 
it  may  become  the  site  of  an  acute  inflammation  (diverticulitis) 
from  foreign  bodies  or  intestinal  infection,  and  resemble  appendi- 
citis in  its  symptomatology. 

2.  It  may  remain  patent  wholly  or  in  part  and  attached  to  the 
umbilicus,  giving  rise  to  several  important  pathological  conditions.. 
If  the  canal  is  open  throughout  its  entire  extent  there  results  a 
fistula  which  discharges  mucus  or  feces.  After  the  cord  has  dropped 
off  a  small  cherry-red  mass  is  found  at  the  umbilicus  with  a  dimp- 
ling at  the  center  through  which  a  probe  can  be  passed  for  several 
inches  and  from  which  is  discharged  at  first  mucus  and  later  on 
fecal  material.  The  velvet-like  mucous  membrane  leads  to  an  easy 
recognition  of  the  nature  of  this  condition. 

This  eversion  of  the  mucosa  may  precede  a  very  troublesome 
condition ;  for  as  the  child  cries  and  strains  a  hernia  of  the  mucous 
membrane  forms,  and  as  the  fistulous  opening  enlarges  the  intestinal 
wall  itself  is  dragged  out,  and  a  prolapsus  of  the  small  bowel  results 
in  acute  strangulation. 

If  the  diverticulum  persists  as  a  cord  inside  the  abdomen,  it 
may  remain  so  during  life  without  causing  trouble;  or,  on  the 
other  hand,  it  may  be  the  cause  of  intestinal  strangulation. 

Umbilical  Cysts. — If  the  canal  adjoining  the  umbilicus  only 
remains  open,  and  the  secretion  within  the  unobl iterated  portion 
accumulates,  a  cyst  is  formed  which  lies  between  the  skin  and 
aponeurosis;  or  if  the  deeper  portion  of  the  duct  is  involved  an 
intraperitoneal  cyst  may  be  formed. 

Umbilical   adenoma    is    caused    by   the    adenoid    tissue    of   the 


468  AFFECTIONS  OF  THE  ABDOMEN 

diverticulum  or  its  remains,  which  forms  a  small,  red,  mulberry- 
shaped  tumor  at  the  umbilicus.  These  tumors  are  pedunculated 
arid  have  no  lumen,  by  which  they  are  distinguished  from  diverticu- 
lous  fistula  complicated  with  prolapse  of  the  mucosa. 

Diagnosis. — The  diagnosis  of  pathological  lesions  in  infants  in 
the  region  of  the  umbilicus  is  not  only  important,  but  often  very 
complicated.  When  the  diverticulum  is  patent  and  a  fecal  fistula 
exists  the  diagnosis  is  simple,  but  this  condition  is  extremely  rare. 
It  is  usual  to  find  only  a  slight  mucopurulent  discharge  through  a 
small  opening.  Under  such  circumstances  it  will  be  necessary  to 
know  whether  the  discharge  comes  from  a  fistula  of  the  diverticuium 
or  from  a  fistula  of  the  urachus. 

When  it  is  possible  to  pass  a  probe  through  the  fistula  valuable 
information  may  be  gleaned  from  the  direction  which  the  probe 
takes.  In  fistula  of  the  urachus  the  direction  is  toward  the  bladder. 

Note  the  reaction  of  the  discharge.  Acid  reaction  suggests 
urinary  components  and  fistula  of  the  urachus ;  alkaline  reaction 
makes  a  Meckel's  diverticulum  more  probable.  Methylene  blue 
(subcutaneous  injections)  may  be  used  as  a  diagnostic  measure. 
When  a  fistula  of  the  urachus  is  present  blue  urine  will  be  observed 
coming  from  the  opening. 

It  is  well  to  note  that  umbilical  cysts  are  rare  and  that  their 
diagnosis  presents  no  difficulty. 

Umbilical  adenomata  must  be  differentiated  from  a  patent 
diverticulum  with  an  eversion  of  the  intestinal  mucosa,  and  also 
from  an  umbilical  granuloma.  Note  that  adenomata  have  no  orifice 
at  the  center,  while  a  diverticulum  with  a  prolapsed  mucosa  has  a 
central  orifice  which  is  recognized  on  its  surface.  And  if  the  in- 
testinal wall  itself  is  herniated  there  is  either  a  furrow  surrounding 
the  central  mass  or  two  orifices. 

While  the  granuloma  and  adenoma  have  no  orifice  or  lumen, 
yet  the  granulomata  are  flatter,  softer,  more  of  a  pink  color,  and 
secrete  pus ;  while  the  adenoma  is  more  prominent,  bright  red  in 
color,  and  secretes  mucus. 

It  is  well  to  be  sure  about  the  diagnosis  before  excising  such 
growths,  as  there  is  always  danger  of  cutting  a  loop  of  intestine. 


MALFOKMATIONS   OF   THE   URACHIJS  469 

Furthermore,  in  all  cases  of  intestinal  obstructions  in  children 
with  other  deformities,  such  as  hare-lip,  cleft  palate,  etc.,  always 
recall  the  possibility  of  an  existing  Meckel's  diverticulum. 

Treatment. — In  cases  of  patent  diverticnlum  or  cyst  of  the 
diverticulum,  the  canal  should  be  extirpated  through  a  small  incision 
through  the  median  edge  of  the  rectus  muscle.  The  entire  canal  to 
its  junction  with  the  intestine  should  be  removed,  the  stump  in- 
verted and  covered  over  with  Lembert  sutures.  Granulomata  and 
adenomata  should  be  simply  excised  according  to  the  usual  surgical 
technique.  As  Cullen  observes  it  is  important  to  ligate  the  pedicle 
of  an  adenoma  as  it  usually  contains  vessels  of  goodly  size;  and 
further,  in  all  such  cases  the  parents  should  be  cautioned  to  watch 
the  child  carefully,  because  in  a  certain  percentage  of  these  children 
a  Meckel's  diverticulum  exists  and  is  firmly  attached  to  the  umbili- 
cus. If  at  any  time  signs  of  intestinal  obstruction  develop  an 
exploratory  section  should  at  once  be  performed. 


MALFORMATIONS   OF   THE   URACHUS 

The  urachus  is  normally  obliterated  about  the  middle  of  intra- 
uterine  life,  but  in  certain  cases  it  remains  wholly  or  partly  open 
and  gives  rise  to  urinary  fistula?  of  the  umbilicus  or  to  cysts  of 
the  urachus. 

Urinary  Fistulae  of  the  Umbilicus. — Urinary  fistula?  of  the  um- 
bilicus although  quite  rare  are  found  more  frequently  in  boys  than 
girls.  As  soon  as  the  cord  is  cut  the  permeable  urachus  is  opened 
and  a  congenital  urinary  fistula  is  established. 

When  the  natural  urinary  outlet  is  unobstructed  there  are  only 
a  few  drops  of  urine  which  ooze  through  the  fistula.  If,  on  the 
contrary,  the  normal  outlet  is  obstructed  by  a  phimosis  or  a  mem- 
branous diaphragm  of  the  urethra,  all  the  urine  passes  through  the 
fistulous  opening.  It  is  obvious  that  this  canal  may  easily  become 
infected  and  the  discharge  become  purulent,  and  that  eventually 
the  bladder  itself  may  participate  in  this  infection. 

The  DIAGNOSIS  is  made  by  the  character  of  the  discharge.     The 


470  HEENIA 

urinary  components  are  recognized  by  the  acid  reaction,  by  the 
appearance  of  blue  discharge  after  the  subcutaneous  injection  of 
methyl  blue,  and  by  the  passage  of  the  probe  in  the  direction  of 
the  bladder. 

The  TREATMENT  consists  in  removing  any  obstructions  if  they 
exist  to  the  normal  urinary  outlet.  Do  not  waste  time  by  employ- 
ing such  futile  methods  as  compression  or  the  actual  cautery,  but 
plan  to  excise  the  fistulous  tract  to  its  connection  with  the  blad- 
der, where  it  usually  broadens  out  like  a  cone.  Suture  the  bladder 
and  close  the  abdominal  wound  with  drainage. 

Cysts  of  the  Urachus. — If  a  portion  only  of  the  urachus  is  per- 
meable, cysts  may  be  produced  occupying  the  median  line  below  the 
umbilicus.  These  cysts  may  attain  considerable  volume  and  some- 
times contain  calculi. 

The  TREATMENT  of  cysts  that  do  not  communicate  with  the 
bladder  is  extirpation. 


CHAPTER  LVI 

HERNIA 

In  the  surgery  of  children  hernia  plays  an  important  role,  first, 
because  of  its  frequency;  second,  because  of  its  etiology;  and  third, 
because  it  is  more  amenable  to  treatment  and  ultimate  cure,  either 
by  supports  or  operation,  than  in  the  adult. 

Etiology. — Hernia  in  children  is  congenital  (the  exception  to 
this  rule  is  rare).  It  is  -a  developmental  defect  just  as  hare-lip, 
and  the  causes  which  produce  either  are  practically  the  same. 

Defective  development,  due  to  a  low  vital  index,  explains  the 
frequency  with  which  hernia  is  associated  with  other  congenital  de- 
formities. Note  its  special  frequency  among  the  weak,  premature, 
and  degenerate;  also  its  hereditary  nature,  occurring  in  families 
where  there  are  other  stigmata  of  degeneration. 

.   Either  failure  to  close  the  openings  during  fetal  life  or  weak- 
ness at  these  points  due  to  late  closure  is  the  rational  explanation 


UMBILICAL   HERNIA  471 

of  the  hernias  of  childhood;   it  will  also  be  found  that   acquired 
hernias,  even  in  adults,  are  very  rare. 


UMBILICAL   HERNIA 

Umbilical  hernia  is  very  frequent  in  childhood  because  it  will 
be  recalled  that  the  umbilicus  is  a  potential  center  of  congenital 
defects.  The  umbilicus  is  an  abdominal  cicatrix  which  marks  the 
site  of  the  umbilical  ring  through  which  the  placental  vessels  pass 
in  intrauterine  life.  Hence,  defective  development  of  the  abdominal 
wall  may  leave  a  median  gap  which  persists  after  birth,  or  imper- 
fect closure  of  the  cicatrix  may  leave  a  weak  spot  through  which  a 
hernia  appears  a  few  days  or  weeks  after  birth.  Umbilical  hernia 
must  not  be  confused  with  exomphalocele,  which  is  not  a  true  hernia 
at  all.  Exomphalocele  is  a  developmental  defect  of  the  wall  of  the 
abdomen  in  which  portions  of  the  viscera  remain  external  to 
and  are  not  inclosed  within  the  abdominal  cavity.  (See  p. 
466.) 

The  true  umbilical  hernia  of  childhood,  whether  present  at  birth 
or  occurring  a  few  days  or  weeks  after  birth,  may  be  properly  con- 
sidered under  the  term  infantile  umbilical  hernia. 

Pathology. — Infantile  umbilical  hernia  may  present  under  two 
aspects.  First:  It  may  present  at  birth  and  occupy  the  cord  at 
its  site  of  implantation.  These  hernias  are  frequently  so  small  that 
they  pass  unrecognized  and  may  be  compromised  in  ligating  the 
cord.  Hence,  in  tying  off  the  umbilical  cord  the  presence  of  gut 
should  first  be  excluded  or  it  may  be  caught  in  the  ligature. 
Second:  The  hernia  may  occur  a  few  days  or  a  few  weeks  after 
birth,  before  the  cicatrix  has  firmly  closed  the  ring.  Excessive 
coughing,  crying,  straining  imposed  by  constipation,  or  phimosis,  in 
conjunction  with  a  weakened  ring  is  sufficient  to  bring  about  this 
condition. 

The  coverings  of  the  hernia  consist  of  skin  and  peritoneum,  and 
at  the  apex  of  the  protrusion  the  skin  and  peritoneum  are  usually 


472  HERNIA 

adherent.  The  contents  of  the  sac — in  large  hernias — consist  of 
small  intestine;  in  small  hernias  a  portion  of  the  omentum  is  usually 
found  adherent  to  the  sac,  which  prevents  the  complete  closure  of 
the  ring.  It  may  be  said  in  general  that  these  small  umbilical 
hernias  are  extremely  frequent,  usually  benign,  and  have  a  tendency 
to  spontaneous  cure. 

Symptoms. — Usually  there  is  present  at  the  umbilical  ring  a  small 
globular  tumor  about  the  size  of  a  pea  which  becomes  tense  on 
crying  or  straining.  It  is  easily  reducible  and  contents  of  sac  disap- 
pear with  a  gurgle.  There  is  little  serious  general  disturbance, 
nothing  more  than  colic  and  digestive  disorders.  There  is  no 
tendency  to  strangulation.  Umbilical  hernia  must  not  be  con- 
founded with  congenital  tumors  of  the  umbilicus  (see  p.  467).  Its 
reducibility  and  accompanying  gurgle  will  suggest  the  nature  of 
the  tumor. 

Treatment. — The  first  indication  in  the  treatment  of  infantile 
umbilical  hernia  is  the  elimination  of  all  factors  which  are  found 
to  be  causing  increased  intra-abdominal  pressure,  such  as  disturb- 
ance of  digestion,  difficult  micturition,  constipation,  phimosis,  and 
coughing. 

In  the  management  of  infantile  umbilical  hernia  keep  in  mind 
the  fact  that  the  tendency  of  these  hernias  is  toward  spontaneous 
cure,  provided  reduction  is  maintained  continuously.  Reduction  is 
of  little  value  unless  retention  is  complete  and  continuous.  "A 
single  .protrusion  may  destroy  the  work  of  several  weeks  of  re- 
tention." 

Hence  the  fundamental  principle  of  treatment  is  reduction  and 
retention.  The  reduction  should  be  complete,  and  the  retention 
continuous.  To  accomplish  this  either  palliative  or  operative  meas- 
ures may  be  employed.  Since  the  tendency  of  these  hernias  is 
toward  spontaneous  cure,  palliative  measures  should  be  our  first 
recourse. 

Rule :  Use  palliative  measures  for  six  months — if  without  re- 
sults, consider  radical  operation. 

PALLIATIVE  TREATMENT.— The  object  of  this  treatment  is  to 
assist  nature  in  her  efforts  toward  a  spontaneous  cure.  All  that  is 


UMBILICAL   HERNIA 


473 


necessary  is  to  continuously  maintain  reduction  without  interfering 
with  the  closure  of  the  ring.  The  simplest  and  most  effective 
method  is  to  approximate  the  edges  of  the  ring  by  the  proper  appli- 
cation of  adhesive  straps  to  the  abdomen.  The  application  of  padded 
buttons  and  coins  over  the  ring  is  usually  unnecessary  and  ofttimes 
does  more  harm  than  good. 

Method. — Prepare  two  strips  of  zinc  oxid  adhesive  plaster  two 
and  one-half  inches  wide  and  long  enough  to  reach  well  around  to- 
ward the  back  of  the  patient.  After  careful  cleansing  of  the  umbil- 
icus, reduce  the  contents  of  the  hernia,  and  place  over  the  ring  a 
small  piece  of  absorbent  cotton  which  has  been  well  powdered— 
the  purpose  of  this  cotton  is  simply  to  prevent  excoriation  of  the 
folds  of  the  skin. 

While  the  umbilicus  is  pushed  in,  the  adhesive  strips  are  ap- 
plied obliquely  over  the  abdomen  so  that  they  cross  at  the  umbilicus ; 
as  the  straps  are  brought  across,  the  skin 
along  the  median  line  is  folded  inward 
so  as  to  overlap  the  ring  and  thus  form 
an  excellent  support  for  maintaining 
reduction.  (Fig.  174.)  To  be  success- 
ful this  treatment  must  be  continuous. 
It  must  be  worn  day  and  night.  The 
failures  are  usually  in  children  deprived 
of  vigilant  and  intelligent  nursing.  Ex- 
coriations of  the  skin  are  to  be  avoided 
by  frequent  bathing  and  sponging 
with  alcohol,  special  care  being  given 
to  the  folds  of  the  skin  which 

.  ,         ,   FIG.    174. — METHOD    OF    APPLYING 

overlap    the    ring.      A    well-powdered        ADHESIVE   STRIPS  FOR  MAIN- 

,•11  £  TAINING   REDUCTION  IN  INFAN- 

piece    of    absorbent    cotton    frequently        TILE  UMBILICAL  HEKNIA. 
changed  will  usually  prevent  irritation. 

If  the  tender  skin  will  not  tolerate  adhesive  strips,  then  use  a 
carefully  applied  binder  or  a  rubber  bandage. 

Caution. — Whenever  the  adhesive  straps  are  removed,  or  the 
binder  changed  for  purposes  of  cleanliness,  always  maintain  the 
hernia  reduced  ly  pressure  with  the  fingers  until  new  retention 


474  HERNIA 

straps  are  applied.  A  single  protrusion  will  destroy  what  it  has 
taken  weeks  to  accomplish. 

OPERATIVE  TREATMENT. — -Indications. — First,  in  irreducible 
and  strangulated  umbilical  hernia  it  is  necessary  to  operate 
promptly ;  these  conditions,  however,  are  very  rare.  Second,  in  large 
hernias  of  the  umbilical  cord  operation  should  be  done  preferably 
the  second  or  third  day.  Third,  if  after  six  months'  palliative 
treatment  no  results  are  obtained,  radical  operation  should  be  con- 
sidered. If  the  nutritional  index  is  sufficiently  high  there  is  no 
reason  to  delay  until  the  hernia  is  larger,  adhesions  firmer,  and 
operation  more  difficult. 

An  early  operation  can  be  done  by  a  skilled  surgeon  with  little 
danger,  since  only  a  few  drops  of  ether  are  necessary,  the  time  con- 
sumed is  not  more  than  ten  minutes,  healing  is  rapid,  and  the  re- 
sults satisfactory. 

Technique  of  Operation. — Prepare  the  field  of  operation  by 
lightly  painting  the  skin  with  tincture  of  iodin  (half  strength). 
Keep  in  mind  the  fact  that  the  thickness  of  tissue  which  protects 
the  hernial  contents  is  very  slight ;  the  sac  is  very  thin  and  partly 
adherent  to  the  skin. 

Make  a  small  curved  incision  below  the  umbilicus  about  one-half 
inch  from  the  edge  of  the  hernia. 

Find  the  line  of  cleavage  and  separate  the  sac  as  far  as  pos- 
sible. 

Open  the  sac,  leaving  that  portion  which  is  adherent  to  the 
skin  undisturbed. 

Reduce  the  herniai  contents. 

Ligate  the  sac  close  to  its  base,  bring  the  edges  of  the  ring  to- 
gether by  cross  sutures,  and  suture  the  skin  flap  in  position.  The 
umbilicus  should  not  be  extirpated,  since  it  has  a  cosmetic  value 
which  warrants  its  preservation. 

The  wound  should  be  dressed  with  a  small  pad  of  sterile  gauze 
held  in  position  by  cross  strips  of  adhesive  plaster. 

Healing  is  usually  complete  by  the  fifth  day,  when  sutures  may 
be  removed.  The  adhesive  strips  may  be  dispensed  with  on  the 
tenth  day. 


INGUINAL    HEENIA 


475 


INGUINAL   HERNIA 


transv. 
Fascia 


Normal  and  Pathological  Anatomy. — Inguinal  hernia  in  children 
is  congenital;  it  is  a  developmental  defect  due  either  to  imperfect 
or  delayed  closure  of  a  fetal  process.  No  adequate  conception  of 
inguinal  hernia  is  possible  without  recalling  the  various  steps  in 
the  evolution  and  migration  of  the  testicle. 

Note,  first,  that  in  the  early  part  of  intrauterine  life  the 
testicle  lies  in  the  abdominal  cavity  behind  the  peritoneum.  From 
this  position  it  migrates 
through  the  abdominal 
wall,  and  eventually 
reaches  the  scrotum  dur- 
ing the  ninth  month. 
Second,  the  pathway 
which  the  testicle  takes 
through  the  abdominal 
wall  is  the  future  in- 
g  u  i  n  a  1  canal.  Third, 
while  the  testicle  retains 
its  retroperitoneal  posi- 
t  i  o  n  throughout  this 

process     of     evolution,     it    FIG.    175. — MIGRATION  OF  TESTICLE  AND  TUBE-LIKE 
...  .  PROCESS  OF  PERITONEUM  PROJECTED   INTO   THE 

maintains  a  very  impor-         SCROTUM. 
tant    peritoneal    relation- 
ship which  must  be  well  understood,  viz. :  while  the  testicle  is  migrat- 
ing toward  the  scrotum,  a  titbelike  process  of  peritoneum  is  projected 
into  the  scrotum   (Fig.   175) — the  processus  vaginalis — which  just 
before  birth  assumes  a  relationship  as  shown  in  Fig.  176. 

The  final  normal  disposition  of  the  processus  vaginalis,  which 
is  usually  complete  at  birth,  is  as  follows:  Its  upper  end  is 
closed;  the  lower  portion  in  relation  with  the  testicle  becomes  the 
tunica  vaginalis  of  the  testicle ;  the  intermediate  portion  atrophies. 

(Fig.  177.) 

Supposing  this  normal  obliteration  of  the  processus  vaginalis  is 


476 


HERNIA 


transy. 
Fascia 


five,  vagin: 
perform. 

Tunica  vagin 
propria  ' 


FIG.  176.— RELATION  OF  TESTICLE  TO  VAGINAL   PROCESS 
OF  PERITONEUM  JUST  BEFORE  BIRTH. 


not  complete  at  birth, 
or  it  remains  imper- 
fectly closed,  as  in 
Fig.  176,  it  is  obvi- 
ous that  it  needs  but 
a  slight  excess  of 
intra-abdominal  pres- 
sure to  force  an  in- 
testinal loop  into  the 
preformed  sac.  Fur- 
thermore, it  is  esti- 
mated that  in  one- 
h  a  1  f  the  new-born 
there  is  an  open 
processus  vaginalis 
which  usually  obliterates  during  the  first  weeks.  It  is  possible, 
however,  for  this  process  to  remain  open  without  causing  the  pal  lent 
any  trouble  during  life.  Such  a  condition  is  made  possible  when 
the  canal  is  guarded  by  good  muscular  rings. 

Frequency. — Inguinal  hernia  is  much  more  frequent  in  the  male 
because  of  the  inguinal 
canal — the  weak  spot 
made  by  the  pathway  of 
the  migrating  testicle. 
In  the  female  the  canal 
of  Nuck  is  the  analogue 
of  the  inguinal  canal. 
It  transmits  the  round 
ligament  accompanied 
by  a  prolongation  of 
peritoneum  correspond- 
ing to  the  processus  va- 
ginalis. Hence,  in  the 
female  inguinal  hernia 

presents  in  the  canal  of      FIG.  177- — THE  FINAL  AND  NORMAL  DISPOSITION  OF 

THE  VAGINAL  PROCESS — USUALLY  COMPLETE  AT 
BIRTH. 


transv. 
Fascia 


Tunica 

vaginal^ 

propria. 


INGUINAL    HERNIA 


477 


It  will  also  be  observed  that  inguinal  hernia  is  more  frequent  in 
boys  than  in  girls  (40-1)  because  of  the  developmental  difference 
in  the  inguinal  canal. 

Etiology. — It  is  evident  that  the  unobliterated  processus  vayinalis 
is  the  preformed  sac  which  is  the  potential  cause  of  a  congenital 
inguinal  hernia  whenever  intra-abdominal  pressure  exceeds  inter- 
muscular  abdominal  support.  Hence,  a  congenital  inguinal  hernia 
has  no  reference  to  the  time  of  its  appearance,  but  to  the  congenital 
defect  which  invites  it.  It  may  be  present  at  birth,  it  may  appear 
before  puberty  or  after 
puberty. 

Site. -^Inguinal  her- 
nia is  more  frequent  on 
the  right  side,  not  be- 
cause of  any  marked 
difference  in  intra-ab- 
dominal pressure  in  the 
two  sides,  but  because 
the  unobliterated  pro- 
cessus vaginalis  is  more 
frequent  on  the  right 
side. 

Pathology.  —The  her- 
n  i  a  1  contents  usually 
consist  of  loops  of  small 

intestine;  omentum  is  found  less  frequently,  because  in  children  the 
omentum  is  not  well  developed,  and  still  more  rarely  we  find  the 
cecum,  the  appendix,  and  the  ovary.  The  presence  of  the  ovary 
in  the  sac  may  be  a  coincident  congenital  defect — the  ovary  approxi- 
mating the  male  type  in  migrating  to  the  inguinal  canal  and  labia 
major  a. 

The  hernial  contents  are  almost  always  reducible — a  notable 
exception  to  this  rule  is  the  frequency  with  which  adhesions  are 
found  with  the  sac  when  the  cecum  and  appendix  form  its  con- 
tents. If  in  a  child  a  right-sided  hernia  cannot  be  reduced  it  is 
probable  that  the  cecum  or  appendix  is  in  the  sac. 


FIG.  178. — CONGENITAL  INGUINAL  HERNIA. 


478  HERNIA 

Symptoms. — Functional  symptoms  are  of  little  value.  In  the 
mind  of  the  parent  certain  intestinal  colics  are  attributed  to  the 
hernia,  but  the  only  reliable  evidence  is  the  demonstration  of  the 
presence  of  an  inguinoscrotal  tumor  (Fig.  178)  which  gives  an  im- 
pulse when  the  child  cries  or  makes  any  effort  that  increases  intra- 
abdominal  pressure,  and  on  lying  down  recedes;  or  by  gentle  pres- 
sure is  reduced  with  a  gurgle.  Furthermore,  after  reduction,  in- 
crease in  the  size  of  the  ring  may  be  determined  by  invaginating  the 
scrotum  with  the  index  finger  to  ascertain  if  it  will  admit  the  finger 
tip. 

Gurgling  occurring  coincident  with  reduction  is  patliognomonic. 
However,  in  young  children  the  picture  is  not  always  well  defined — 
there  are  other  conditions  engrafted  on  the  same  congenital  defect, 
such  as  undescended  testicle,  hydrocele,  and  cysts  of  the  cord,  which 
must  be  carefully  differentiated,  since  they  have  an  important  prac- 
tical relation  to  hernia.  Hence,  when  an  inguinal  hernia  is  sus- 
pected in  a  child  the  first  duty  of  a  surgeon  is  to  eliminate  possible 
errors  of  diagnosis.  Do  not  be  satisfied  with  one  examination. 
Several  examinations  are  often  advantageous,  especially  in  very 
young  children. 

Differential  Diagnosis. — First:  Eliminate  undescended  testicle. 
Examine  the  scrotum  and  ascertain  if  the  testicle  is  in  its  normal 
position.  If  the  testicle  is  permanently  absent  (not  due  to  cremas- 
teric  reflex)  the  hernia  is  probably  complicated  by  an  undescended 
testicle  (see  p.  542).  Careful  examination  of  the  inguinal  mass 
in  reference  to  consistency  and  tenderness  will  disclose  its  nature. 
In  hernia  the  tumor  is  elastic  and  painless  on  pressure.  In  un- 
descended testicle  the  tumor  is  firm  and  painful  on  pressure. 

Second:  Eliminate  congenital  hydrocele.  Hydrocele  is  very 
frequently  mistaken  for  hernia,  Note  the  following  differentials : 

Hernia  Congenital  Hydrocele 

Reduction    sudden    and      with  Reduction  slow  and  silent. 

gurgling. 

Not  translucent.  Translucent. 

Reappears  rapidly  on  coughing.  Reappears  slowly. 


INGUINAL    HERNIA  479 

The  light  test  in  infants  cannot  be  always  used  as  a  differential, 
since  light  is  often  freely  transmitted  through  the  gut  in  infants. 

Third :  Encysted  hydrocele  of  the  cord  presents  a  tense,  rounded 
tumor,  the  content  of  which  is  not  reducible,  but  its  extreme 
mobility  permits  it  to  be  forced  en  masse  toward  the  internal  ring 
and  thus  mislead  by  an  apparent  reduction.  There  is  no  impulse 
on  coughing  or  straining. 

Complications. — In  addition  to  the  complications  of  undescended 
testicle  and  hydrocele  already  noted,  we  may  mention  tuberculosis 
of  the  sac,  which  resembles  an  adherent  omental  hernia  by  present- 
ing a  dull,  irreducible  tumor.  In  the  presence  of  a  swollen  testicle 
this  condition  may  be  suspected.  It  is  well  to  keep  in  mind  the 
inflammatory  symptoms  resembling  the  "acute  abdomen"  which 
may  present  in  undescended  testicle,  torsion  of  the  cord,  and  in- 
flamed hydrocele  of  the  cord. 

Strangulated  hernia  is  rare  in  childhood.  It  occurs  most  fre- 
quently during  the  first  two  years.  It  is  not  only  a  rarer  compli- 
cation, but  it  is  less  grave  than  in  adults  and  gangrene  of  the  gut  is 
unusual.  This  is  easily  explained  by  the  elasticity  and  the  little 
resistance  of  the  young  tissues  forming  the  inguinal  canal.  The 
symptoms  of  strangulation  are  those  of  acute  intestinal  obstruction, 
and  are  similar  to  a  like  condition  in  the  adult;  but  they  are  more 
acute  than  in  the  adult.  The  child  cries  with  pain  and  draws  the 
legs  up,  there  is  sudden  irreducibility  of  a  hernia  which  becomes 
tense  and  painful,  this  is  followed  by  vomiting  and  stoppage  of  gas 
and  feces :  The  indication  for  immediate  relief  is  imperative. 

Treatment. — Two  widely  different  and  distinct  indications  pre- 
sent themselves  in  dealing  with  inguinal  hernia  in  children: 
(a)  the  treatment  of  strangulated  hernia;  (b)  the  treatment  of 
reducible  hernia. 

TREATMENT  OF  STRANGULATED  HERNIA. — The  treatment  of 
strangulated  hernia  is  immediate  and  resolves  itself  into  two  pro- 
cedures: first,  taxis — reduction  by  manipulation;  second,  operation 
— radical  cure. 

Taxis. — Reduction  by  manipulation  is  more  successful  in  chil- 
dren than  in  adults,  and  if  done  early  and  according  to  well-defined 


480 


HEKNIA 


rules  it  is  often  efficacious  in  giving  relief  until  an  opportune  time 
can  be  selected  for  a  radical  cure. 

Rule:  Try  taxis  if  the  strangulation  has  not  existed  for  more 
than  twelve  hours.  The  strangulation  is  less  tense  in  children  than 
in  adults,  hence  the  period  during  which  taxis  may  be  tried  is  more 
prolonged. 

Method  of  Taxis. — Place  the  patient  in  a  warm  bath.     Produce 

a  light  narcosis  by  a  few 
drops  of  ether.  Lift  the  pa- 
tient straight  up  by  the  legs, 
letting  the  body  hang  down; 
then  pull  the  scrotum  up 
and  shake  the  contents  back 
into  the  abdominal  cavity 
(Spitzy).  (Fig.  179.)  This 
position  favors  the  coopera- 
tion of  all  the  natural  forces 
—the  relief  of  congestion, 
the  influence  of  gravity,  the 
pull  of  the  mesentery — in  re- 
ducing the  strangulated  loop, 
and  renders  dangerous  man- 
ual pressure  unnecessary. 

Operation. — A  radical  op- 
eration for  strangulated  her- 
nia should  be  done  at  once 
if  taxis  fails.  The  operation 
for  strangulated  hernia  does 
not  differ  in  a  general  way 

from  the  same  procedure  in  the  adult,  but  there  are  special  indica- 
tions in  children  which  require  special  emphasis  and  they  will  have 
their  proportional  weight  in  these  cases  which  require  surgical  dis- 
crimination. 

Special  indications : 

(1)  When  there  is  doubt  as  to  the  viability  of  the  gut,  remember 
that  young  children  do   not  bear  well   resection  of  the   intestine; 


FIG.  179. — METHOD  OF  SHAKING  THE  HERNIAL 
CONTENTS  BACK  INTO  THE  ABDOMINAL 
CAVITY.  (Spitzy.) 


INGUINAL    HEKXIA  481 

yet  their  tissues  have  a  great  power  of  recuperation.  Hence: 
Reduce  a  doubtful  loop  of  gut  rather  than  take  the  risk  of  resection 
(apt  to  be  fatal  in  young  children). 

(2)  When  the  gut  is  not  viable  and  not  reducible.  Here  it  is 
a  question  of  resection  or  artificial  anus ;  a  choice  between  a  possible 
immediate  fatality  through  shock,  and  an  ultimate  fatality  through 
malnutrition. 

Spitzy  believes  that  resection  is  the  procedure  of  choice  because 
larger  children  will  stand  resection  fairly  well,  and  small  children 
are  not  benefited  by  an  artificial  anus.  Malnutrition  and  the 
presence  of  a  fecal  fistula  ultimately  necessitate  resection. 

TREATMENT  OF  REDUCIBLE  HERNIA. — The  fundamental  prin- 
ciple in  the  treatment  of  simple  inguinal  hernia  is  reduction  and 
retention.  Remove  all  causes  of  increased  intra-abdominal  pressure, 
such  as  tight  belly  bands,  indigestion,  constipation,  phimosis,  stone 
in  the  bladder,  etc.,  which  cause  crying  and  straining.  Keep  the 
hernia  continuously  reduced  by  closing  the  hernial  opening:  (a)  by 
mechanical  appliances — truss;  (b)  by  radical  cure — operation.  In 
infants  it  is  possible  to  obtain  a  spontaneous  cure  by  maintaining 
continuous  reduction.  After  the  second  year  the  chances  of  cure 
by  this  method  are  doubtful.  Surgical  treatment  of  hernia  in 
childhood  is  eminently  satisfactory  and  restores  normal  conditions 
at  once. 

Rule :  In  infants  apply  truss  continuously  as  soon  as  the  hernia 
is  diagnosed. 

After  the  second  year  consider  radical  operation  if  the  nutri- 
tional index  is  favorable. 

(a)  Treatment  by  Truss. — As  soon  as  a  hernia  is  diagnosed  in 
an  infant  apply  a  truss  continuously  night  and  day.  Treatment  by 
truss  can  be  efficient  only  when  the  principles  of  the  treatment  are 
intelligently  understood  and  its  application  is  in  the  hands  of  a 
vigilant  and  careful  nurse.  It  must  be  well  understood  that  the 
object  of  the  truss  is  two-fold — to  obtain  if  possible  a  spontaneous 
cure,  and,  failing  in  this,  to  carry  the  child  safely  over  the  first 
few  years  till  a  proper  time  can  be  selected  for  operation. 

First:    A   truss  to   be   efficacious  must  be  worn  continuously. 


482  HEKNIA 

The  object  of  the  truss  is  to  keep  the  hernia  reduced — to  prevent 
its  escape  into  the  sac — to  bring  about  obliteration  of  the  sac. 
Hence  the  support  must  be  continuous — day  and  night,  during  the 
bath,  when  the  truss  is  changed.  From  the  time  the  truss  is  ap- 
plied there  must  not  be  a  moment  when  the  hernial  opening  is  left 
without  support.  In  case  the  child  should  cry  or  cough  or  strain 
during  a  moment  when  the  opening  is  unsupported  the  hernia  may 
again  protrude  and  spoil  the  results  obtained  by  months  of  treat- 
ment. 

The  Management  of  the  Truss  in  Infants. — This  should  be 
under  the  supervision  of  the  physician,  not  the  truss  maker.  The 
physician  should  measure,  select,  fit,  and  make  the  first  application 
of  the  truss.  The  nurse  should  receive  specific  instructions  in 
reference  to  the  purpose  of  the  truss;  the  location  of  the  hernial 
opening;  the  proper  placing  of  the  pad;  the  hygiene  of  the  truss 
and  the  inguinal  region;  the  proper  support  of  the  hernial  open- 
ing by  the  fingers  of  the  nurse  when  the  truss  is  removed  for  cleans- 
ing the  parts. 

This  instruction  is  as  important  as  the  ordering  of  the  truss,  for 
without  it  the  truss  will  accomplish  nothing  but  irritation  to  the 
infant.  Furthermore,  it  should  be  imderstood  that  when  the  physi- 
cian prescribes  a  truss  he  does  not  dismiss  a  patient,  he  accepts  a 
patient  who  is  to  receive  his  professional  care  so  long  as  the  truss 
is  worn. 

It  cannot  be  made  too  emphatic  that  the  cure  of  a  hernia  never 
results  from  the  mere  application  of  a  truss;  it  is  truss  plus  intelli- 
gent supervision. 

The  Truss. — The  mechanical  treatment  of  hernia  does  not  imply 
that  the  treatment  is  to  be  left  to  a  mechanic.  It  is  more  than  the 

mere  prescribing  of  the  truss.     It  implies  accurate  measurement  for 

i 

the  size  of  the  truss;  definite  instructions  as  to  the  type  of  the  truss; 
careful  shaping  of  the  truss  so  that  the  truss  conforms  to  the  patient, 
not  the  patient  to  the  truss. 

Type  of  Truss. — Eliminate  from  consideration  such  unreliable 
relics  as  "hanks  of  worsted"  and  "folded  skeins  of  Berlin  wool" ; 
their  inefficacy  is  only  equaled  by  their  uncleanliness. 


INGUINAL    HEENIA 


483 


In  selecting  a  truss  be  sure  that  it  is,  first,  efficacious;  second, 
cleanly. 

To  be  efficacious  it  must  possess  a  metallic  spring  which  can  be 
so  adjusted  to  the  child  that  it  conforms  to  the  shape  of  the  pelvis; 
and  maintains  a  pressure  that  holds  the  hernia  without  irritating 
the  skin. 

To  be  cleanly  it  must  be  simple  in  design,  waterproof  through- 
out, so  that  it  may  be  unaffected  by  urine  and  frequently  cleansed. 

The  type  of  truss 
which  most  completely 
fulfills  these  require- 
ments  is  the  "Cross- 
body"  truss,  which  es- 
sentially consists  of  a 
pad  with  a  metallic 
spring  surrounding  two- 
thirds  of  the  pelvis  and 
supplied  with  a  strap 
which  completes  the  cir- 
cumference by  being  but- 
toned to  the  pad.  This  is 
also  known  as  the 
"Hood"  truss.  (Fig. 
180.) 

De  Garmo  has  modi- 
fied and  improved  this 

truss  by  substituting  for  the  steel  spring  one  of  German  silver  cov- 
ered with  hard  rubber,  which  is  easily  shaped  and  maintains  a  light 
but  efficient  pressure. 

The  "De  Garmo  Hood"  truss  meets  all  the  indications  of  sim- 
plicity, efficiency,  and  cleanliness,  and  is  the  type  of  truss  to  be 
recommended  in  the  mechanical  treatment  of  hernia  in  young  chil- 
dren. 

Measuring  for  the  Truss. — Have  the  child  lying  on  his  back. 
Take  the  circumference  of  the  pelvis  by  holding  the  end  of  the 
tape  at  the  hernial  protrusion,  which  should  be  marked  with  ink, 


FIG.    180. — CROSS-BODY   TRUSS    APPLIED   TO   LEFT 
INGUINAL  HERNIA.  (De  Garmo.) 


484 


HERNIA 


and  passing  it  around  the  hip  midway  between  the  crest  of  the  ilium 
and  the  great  trochanter — the  resulting  number  of  inches  is  the  size 
required. 

Should  there  be  a  double  hernia  note  the  distance  between  the 
points  of  the  protrusions  (marked  with  ink)  so  that  the  pads  may 
be  properly  located. 

Shaping  the  Truss. — After  the  proper  sized  truss  has  been  pro- 
cured, it  is  next  to  be  shaped  so  as  to  conform  to  the  pelvis  of  the 
patient  who  is  to  wear  it.  No  truss  can  be  said  to  fit  until  it  is 
properly  shaped. 

To  hold  the  hernia  without  irritating  the  skin  it  must  be 
properly  shaped,  and  it  must  be  shaped  by  the  physician.  For  re- 
producing an  accurate 
tracing  of  the  conforma- 
tion of  the  pelvis  the  sim- 
p  1  e  and  efficient  "lead 
tape"  method  of  De  Gar- 
mo  is  recommended. 

This  author  uses  a 
strip  of  sheet  lead  one  inch 
wide,  1-16  inch  thick,  and 
about  15  inches  long. 
"The  end  of  the  tape  is 
placed  over  the  hernia  and 
extends  from  this  point 
across  the  front  of  the  ab- 
domen and  around  the  hip 
of  the  opposite  side  and 
thence  across  the  back. 
(Fig.  181.)  The  lead  is  gently  pressed  to  the  form  of  the  body,  care- 
fully removed,  and  placed  edgewise  upon  a  sheet  of  paper  or  case 
book  of  suitable  size. 

"A  tracing  is  now  made  of  its  inner  surface  with  a  lead  pencil. 
This  will  represent  about  two-thirds  of  the  circumference  of  the 
pelvis  and  when  transferred  to  paper  the  diagram  may  be  com- 
pleted by  turning  the  lead  over  and  completing  the  tracing.  This 


FIG.  181. — SHOWING  METHOD  OF  TAKING  DIAGRAM 
WITH  LEAD  TAPE.  (De  Garmo.) 


INGUINAL    HERNIA 


485 


diagram  gives  the  shape  of  a  section  of  the  hip  taken  on  a  line 
covered  by  the  truss  spring."     (Fig.  182.) 

In  shaping  a  truss  covered  with  hard  rubber  it  must  be  first 
warmed  by  passing  the  spring  through  an  alcohol  name,  otherwise 
the  rubber  will  crack. 

Hygiene  of  the 
Truss. — Since  continu- 
ous pressure  is  the  price 
of  cure,  it  is  evident  that 
the  skin  will  tolerate 
this  treatment  only  with 
the  most  scrupulous 
cleanliness  and  persist- 
ent vigilance. 
The  problem  is  to  pre- 
vent excoriations  of  the 
skin  constantly  subject- 
ed to  pressure  and 
soiled  with  urine. 

To  this  end  the  skin 
and  truss  must  be  kept 
clean  and  dry.  The 

^  .  FIG.  182. — DIAGRAM  OF  Two  PERSONS  \\HOSE  MEAS- 

best       results       are       ob-  UREMENTS  ARE  IDENTICAL.  (De  Garmo.) 

tained    by  having    two 

trusses.  The  truss  is  kept  on  while  the  child  is  being  bathed ;  when 
removed  for  cleansing  the  underlying  skin,  the  nurse  is  instructed  to 
maintain  pressure  with  the  fingers  over  the  hernial  opening.  The 
skin  is  then  cleansed  and  sponged  with  alcohol  and  witch  hazel, 
dusted  with  talcum  powder,  and  the  clean  and  dry  truss  adjusted  in 
place.  This  is  to  be  repeated  as  often  as  necessary  to  keep  the  skin 
clean  and  dry.  Should  excoriations  of  the  skin  occur  apply  zinc  oxid 
ointment. 

The  Physicians  Supervision. — After  the  truss  is  prescribed, 
fitted  and  shaped,  and  full  directions  given  for  the  after  care,  the 
physician's  supervision  is  still  essential.  For  the  child  that  wears 
a  truss  is  a  patient  until  the  hernia  is  cured.  One  important  fact 


486  HERNIA 

must  be  kept  in  mind — the  child  is  growing  and  the  truss  must  be 
changed  and  adjusted  to  meet  the  demands  of  growth.  Hence  the 
patient  should  be  seen  at  regular  intervals,  for  the  mechanical  treat- 
ment of  hernia  in  children  will  be  successful  only  in  proportion  to 
the  careful  supervision  of  the  family  physician. 

(&)  The  Radical  Cure. — There  is  only  one  good  reason  for  de- 
laying the  radical  cure  of  hernia,  and  that  is  to  have  the  nutritional 
index  high  enough  to  insure  safety.  Operation  is  neither  safe  nor 
satisfactory  before  the  age  of  two  years.  The  extreme  thinness  of 
the  sac,  the  diminutive  structures,  and  the  sensitiveness  to  shock 
all  combine  to  make  the  operation  in  infants  difficult  and  delicate. 
After  the  age  of  two  years,  however,  if  the  nutritional  index  is 
sufficiently  high,  there  is  no  reason  for  continuing  the  truss  if  a 
spontaneous  cure  has  not  already  been  obtained.  Operation  is  then 
indicated. 

The  truss  should  be  abandoned  after  the  age  of  two  because: 

(a)  The  chances  of  cure   steadily  diminish  up  to  the  age   of 
puberty. 

(b)  Truss  pressure  causes  atrophy  of  the  underlying  muscles, 
diminishes  the  protection  afforded  by  the  muscles,  and  lessens  the 
chances  of  radical  cure. 

(c)  The  wearing  of  a  truss  interferes  with  proper  exercise  and 
thus  interferes  with  bodily  development.     The  child  who  wears  a 
truss  is  handicapped  in  the  struggle  for  existence. 

(d)  The   cures   by   truss    are   often   apparent,   not   permanent. 
There  are  many  recurrences. 

(e)  Radical  operation  removes  at  once  the  serious  handicap  men- 
tioned above  with  all  its  disagreeable  sequelae,  by  establishing  normal 
conditions. 

(f)  With  the  age  limitation  mentioned  above  it  is  the  author's 
experience  that  the  younger  the  child  the  more  satisfactory  the  re- 
sults of  operation. 

Preparations  for  operation  should  be  of  the  simplest  kind.  A 
dose  of  castor  oil  the  preceding  day;  light  ether  anesthesia;  the 
field  of  operation  lightly  painted  with  tincture  of  iodin  (half 
strength) . 


INGUINAL    HEKNIA  487 

Operation. — There  is  enough  difference  in  the  hernias  of  adults 
and  children  to  warrant  a  difference  in  technique.  In  children  the 
sac  is  extremely  thin  and  difficult  to  isolate,  the  inguinal  canal  is 
short,  the  structures  are  diminutive,  and  what  is  required  most  of 
all  is  a  simple,  delicate,  and  rapid  technique. 

The  Bassini  operation — the  standard  operation  in  adults — can 
he  replaced  by  a  much  simpler  procedure  giving  equally  good  results. 
The  author  reserves  the  Bassini  operation  for  strangulated  hernias ; 
for  hernias  with  adherent  contents  (cecal  hernia)  ;  for  large  hernias 
in  adolescents;  for  hernias  complicated  with  undescended  testicle. 
For  these  conditions  Bassini's  method  possesses  the  advantages  of 
exposing  the  entire  length  of  the  inguinal  canal  by  splitting  the 
aponeurosis  of  the  external  oblique  and  thus  revealing  at  once  the 
relations  of  the  sac. 

In  the  simple  reducible  hernias  of  childhood  it  is  neither  neces- 
sary to  split  the  aponeurosis  nor  to  transplant  the  cord.  The  one 
essential  feature  in  obtaining  a  permanent  cure  is  careful  isolation 
and  obliteration  of  the  sac.  The  author,  therefore,  prefers  the 
technique  of  Kocher  in  the  management  of  simple  reducible  her- 
nias. 

Technique  of  Operation. — Incision — over  the  inguinal  canal,  and 
as  high  above  the  scrotum  as  possible  to  avoid  contamination  of 
urine — dividing  skin  and  superficial  fascia.  Careful  hemostasis  at 
every  step. 

Identify  the  aponeurosis  of  the  external  oblique  and  the  pillars 
of  the  external  ring.  (Fig.  183.)  Note  the  elements  of  the  cord 
emerging  from  the  ring.  Identify  the  sac  and  proceed  to  separate  it 
from  the  cord  by  careful  dissection ;  open  sac  and  reduce  contents.  If 
the  sac  is  connected  with  the  tunica  vaginalis  of  the  testicle,  divide 
the  sac  transversely,  leaving  the  lower  part  in  connection  with  the 
tunica  vaginalis  of  the  testicle.  The  upper  part  of  the  sac  is  grasped 
by  forceps,  pulled  forcibly  downward,  a  ligature  applied  as  high  as 
possible,  and  the  superfluous  sac  removed.  Or,  in  older  children, 
the  sac  may  be  transposed  a  la  Kocher  by  grasping  the  apex  of 
the  sac  with  curved  forceps  and  pushing  it  along  the  inguinal  canal 
as  far  as  the  internal  abdominal  ring,  where  it  is  protruded  through 


488 


HERNIA 


a  small  opening  in  the  aponeurosis  and  forcibly  pulled  through. 
The  neck  of  the  sac  is  ligated  close  to  the  slit  in  the  aponeurosis,  the 
sac  is  cut  off,  and  the  stump  is  allowed  to  retract  inside  the  ab- 
domen. Finally  the  small  opening  in  the  aponeurosis  is  closed. 
(Kocher.) 

Whichever  disposition  of  the  sac  is  made,  the  canal  is  closed 
by  suturing  the  pillars  of  the  ring,  the  operator  being  careful  not 
to  compress  the  cord.  The  operation  is  completed  by  suturing  the 
skin,  painting  the  wound  with  collodion-aristol  and  securing  a  small 
compress  in  place  by  cross  strips  of  adhesive  plaster. 

This    operation   in   skilled   hands    should   be   completed   in   ten 


FIG.  183. — OPERATIVE  TECHNIQUE  FOR  THE  SIMPLE  REDUCIBLE  HERNIAS  OF  CHILDHOOD; 

A.  Exposure  of  aponeurosis  of  the  external  oblique,  and  sac  separated  from  the  cord; 
B.  Sac  opened,  contents  reduced,  and  sac  ligated.  C.  Sutures  in  place  for  strengthen- 
ing anterior  wall  of  canal,  and  closing  pillars  of  ring. 

minutes  or  less,  and  requires  but  a  few  drops  of  ether.  Observe 
strict  asepsis  and  use  absorbable  sutures. 

After-treatment. — The  dressings  are  removed  at  the  end  of  ten 
days,  after  the  second  day  the  bowels  are  moved  daily;  otherwise 
the  child  is  regarded  as  normal.  In  older  children  active  physical 
exercise  should  be  prohibited  for  six  months  after  operation,  espe- 
cially those  exercises  which  increase  intra-abdominal  pressure. 

The  operation  in  females  does  not  differ  essentially  from  that  in 
males.  It  must  be  remembered  that  the  canal  of  Nuck  is  the  ana- 
logue of  the  inguinal  canal,  and  that  it  lodges  the  round  ligament. 
Hence  absence  of  the  cord  renders  closure  of  the  external  ring  much 
easier,  but  it  is  much  more  difficult  to  find  the  sac.  If  the  ovary  is 


FEMORAL    OR    CRURAL    HERNIA  489 

present  in  the  hernial  contents  the  aponeurosis  should  be  split  and 
the  ovary  reduced  in  the  abdominal  cavity.  The  round  ligament 
should  be  preserved. 


FEMORAL  OR  CRURAL  HERNIA 

Femoral  or  crural  hernia  is  rare  in  children,  though  it  is  found 
both  in  boys  and  girls  (1-2).  It  is  much  more  difficult  to  apply 
an  efficient  truss  in  this  region  and  operation  should  be  considered 
when  the  nutritional  index  warrants  it.  The  operation  differs  in 
no  respect  from  the  operation  in  adults. 


CHAPTER  LVII 

EXSTROPHY    OF    THE    BLADDER 

Exstrophy  of  the  bladder  is  a  developmental  defect  in  which 
there  is  a  failure  of  union  between  the  two  lateral  halves  of  the 
bladder.  This  malformation  affects  not  only  the  anterior  wall  of 
the  bladder,  but  involves  the  abdominal  wall,  the  pubic  symphysis, 
and  the  roof  of  the  urethra.  In  other  words,  the  fissure  extends 
through  the  abdominal  wall  and  into  the  bladder  and  urethra 
(Fig.  184).  Hence,  the  aperture  is  filled  by  the  posterior  wall  of 
the  bladder  and  the  floor  of  the  urethra. 

This  deplorable  condition  is  quite  rare  and  is  most  frequently 
observed  in  boys,  often  associated  with  other  malformations,  such 
as  imperforate  anus,  spina  bifida,  hare-lip,  club  foot,  etc.  As  a  rule 
the  cleft  is  a  complete  one,  though  rarely  the  fissure  involves  only 
the  upper  or  lower  portion  of  the  bladder.  In  some  cases  the  fissure 
involves  only  the  abdominal  wall,  the  bladder  wall  being  complete 
forms  a  hernia  through  the  abdominal  fissure — ectopic  bladder. 

Symptoms. — Below  the  umbilicus  is  found  a  cleft  in  the  abdominal 
wall,  through  which  extrudes  a  moist,  red  shining  mucous  membrane 
with  many  folds  and  corrugations,  which  is  recognized  as  the  mucous 


490 


EXSTROPHY  OF  THE  BLADDER 


lining  of  the  posterior  wall  of  the  bladder  pushed  forward  by  the 
pressure  of  the  intestines.  The  irritated  mucous  membrane  is  very 
vulnerable,  easily  bleeds,  and  is  painful  to  the  touch. 

The  protruding  bladder  wall  is  not  reduced  spontaneously.  In 
small  children  it  may  be  forced  back  by  means  of  a  tampon,  but 
bulges  out  as  soon  as  the  pressure  is  removed. 

In  the  region  of  the  trigone  are  recognized  the  two  ureteral  orifices 
from  which  urine  is  discharging  in  rhythmical  ejaculations.  In  addi- 
tion the  pelvic  ring  is  incomplete,  the  symphysis  pubis  is  open,  and 
the  fissure  continues  to  the  urethra.  In  boys  we  find  a  rudimentary 

penis  with  total  epispadias 
and  undescended  testicle 
on  one  or  both  sides. 

The  changes  in  the  fe- 
rn a  1  e  are  similar — the 
urethra  deprived  of  its 
roof  is  represented  by  a 
groove.  The  labia  majora 
and  minora  are  entirely 
separated,  and  hence  the 
anterior  commissure  of  the 
vulva  is  absent.  The  va- 
gina and  uterus  are  some- 
times double.  The  uterus 
may  be  so  incorporated  with  the  posterior  bladder  wall  that  they  are 
very  difficult  to  separate. 

CLINICAL  COURSE. — As  a  result  of  this  malformation  there  is  a 
constant  dribbling  of  urine  which  soils  the  clothes,  excoriates  the 
skin,  and  envelops  the  patient  with  a  disgusting  odor.  Besides  this, 
inflammation  of  the  vesical  mucosa  renders  the  patient  liable  to  an 
ascending  pyelonephritis  from  infection  through  the  orifices  of  the 
ureters.  Thus  the  patient  is  impossible  as  a  member  of  society; 
the  mortality  is  very  great  from  the  constant  irritation  and  infection 
of  the  urinary  tract;  and  they. are  sexually  impotent. 

Treatment.- — It  is  obvious  that  the  first  indication  is  to  allay  the 
irritating  symptoms  by  protecting  the  exposed  vesical  mucosa  from 


FIG.    184. — EXSTROPHY    OF    THE    BLADDER,    AND 
BILATERAL  UNDESCENDED  TESTICLE.   (Broca.) 


TREATMENT  491 

injury,  by  providing  sanitary  dressings  for  the  incontinence,  and 
by  assuaging  the  painful  excoriations  of  the  adjacent  skin  with  suit- 
able ointments. 

OPERATIVE  RELIEF. — It  must  be  stated  at  the  onset  that  the 
treatment  of  this  condition  by  operative  measures  is  discouraging. 
The  multiplicity  of  the  operative  procedures  suggested  is  sufficient 
proof  of  their  inadequacy.  Not  as  yet  has  surgical  ingenuity  de- 
vised a  satisfactory  reconstruction  of  the  bladder  and  urethra,  with 
a  functionating  sphincter  to  prevent  incontinence. 

Methods. — The  methods  suggested  may  be  divided  into  two 
groups : 

(1)  Autoplastic  Method. — This  method  has  for  its  object  the 
reconstruction  of  a  urinary  reservoir  by  restoring  the  anterior  wall 
of  the  bladder  with  flaps  of  skin  taken  from  the  neighboring  parts. 
The  results  of  this  method  are  uncertain  and  unsatisfactory,  because 
the  newly  constructed  receptacle  is  too  small  for  the  purpose  of  a 
urinary   reservoir;    it  favors   the    decomposition    of   urine    and  the 
formation  of  extensive  phosphatic  deposits,  which  are  irritating  and 
the  frequent  source  of  infection;  and  lastly,  as  there  is  no  sphinteric 
control,  the  patient  is  doomed  to  incontinence. 

(2)  Diversion  of  the  Urinary  Channel  into  the  Lower  Bowel. — 
Among  the  many  operative  procedures  the  suggestion  of  Maydl  is 
the  most  practical.     It  consists  in  excising  from  the  bladder  wall 
its  trigone  with  ureters   and  their   openings,   and   implanting  the 
whole  into  the  wall  of  the  sigmoid  flexure.     The  remainder  of  the 
bladder  is  dissected  out  and  the  abdominal  defect  is  permanent]} 
closed. 

It  is  obvious  that  this  operative  procedure  fulfills  in  a  large 
measure  the  requirements  which  permanent  relief  demands.  The 
urine  drains  into  the  rectum,  where  tolerance  of  its  presence  is 
acquired,  and  it  may  be  retained  for  three  or  four  hours  under  con- 
trol of  the  anal  sphincter.  Thus  by  the  same  operation  the  vesical 
hernia  is  repaired  and  the  incontinence  cured. 

The  objections  to  the  operation  are:  its  complicated  technique 
which  renders  it  too  serious  to  be  undertaken  in  young  infants;  the 
danger  of  hydronephrosis  from  kinking  the  ureters  as  the  trigone 


492      HYPERTROPHIC   STENOSIS  OF  THE  PYLORUS 

is  turned  on  an  axis  of  180°  in  implanting  it  into  the  bowel  wall ; 
the  danger  of  pyelonephritis  by  infection  from  the  bowel  extending 
into  the  ureters  and  renal  pelves. 

In  the  management  of  these  cases  it  is  better  to  abstain  from 
operative  relief  during  the  early  years  of  life  until  the  child  has 
acquired  sufficient  resistance  to  safely  bear  an  operation  so  ex- 
tensive as  the  implantation  of  the  ureters  into  the  bowel.  The 
horrible  character  of  the  deformity  warrants  the  risk  of  any  opera- 
tion which  promises  relief. 

In  the  meantime  instruct  the  parents  to  keep  the  child  as  clean 
as  possible  by  the  use  of  ointments  to  prevent  excoriations  of  the 
skin;  by  protecting  the  bladder  mucosa  with  sterile  gauze  com- 
presses to  prevent  contact  with  the  clothes;  and  to  create  the  most 
favorable  conditions  possible  for  subsequent  operation. 


CHAPTEK  LVIII 

CONGENITAL    HYPEETKOPHIC    STENOSIS    OF    THE    PYLORUS 

While  formerly  this  condition  was  considered  quite  rare,  an 
awakened  interest  in  the  subject  and  a  closer  study  of  the  symptoma- 
tology have  shown  that  it  is  by  no  means  a  rarity,  but  that  hereto- 
fore the  condition  was  simply  overlooked. 

Normal  and  Pathological  Anatomy. — It  will  be  recalled  that  the 
stomach  is  structurally  and  functionally  an  organ  with  a  two-fold 
purpose.  First,  it  is  to  receive  the  food  as  a  reservoir ;  second,  it 
is  to  triturate  the  food  and  prepare  it  for  intestinal  digestion. 

This  two-fold  function  is  plainly  marked  in  its  structure;  for 
about  the  middle  of  the  body  of  the  stomach  there  is  a  distinct  line 
of  demarcation  observed  in  the  thickness  of  the  stomach  wall ;  above 
this  line  the  wall  is  comparatively  thin  and  forms  the  cardiac  pouch; 
below  this  line  and  extending  to  the  pylorus  the  wall  is  thickened 
and  forms  the  pyloric  canal  (Fig.  185).  This  division  of  the 
stomach  into  a  passive  cardiac  pouch  for  storage  and  an  active 
pyloric  canal  for  trituration  exactly  corresponds  to  the  two-fold 


SYMPTOMS 


-193 


gastric  function  and  is  of  considerable  significance  in  the  pathology 
of  hypertrophic  stenosis  of  the  pylorus.  Postmortem  findings 
demonstrate  that  there  is  an  enormous  thickening  of  the  pyloric 
canal,  due  to  a  hypertrophy  of  the  circular  muscular  fibers. 

The  clinical  facts  are  most  rationally  explained  by  presupposing 
spasm,  with  hypertrophy  of  the  pyloric  canal,  and  the  production 
of  a  pyloric  swelling  that  obstructs  the  outlet  of  the  stomach. 

Occurrence. — Hutchinson  makes  the  important  observation  that 
it  occurs  more  frequently  in  males  (80  per  cent.)  and  in  the  first- 
born, but  offers  no  explanation  of 
these  suggestive  facts. 

Symptoms.— The  symptoms  are 
so  characteristic  that  the  condi- 
tion can  scarcely  be  overlooked  by 
a  careful  observer.  It  should 
first  be  noted  that  the  symptoms 
rarely  date  from  birth,  but  usu- 
ally make  their  appearance  from 
two  to  three  weeks  later. 

Vomiting  is  the  most  promi- 
nent and  persistent  feature.  It  is 
apt  to  be  projectile  in  character, 
appears  soon  after  feeding,  and 
consists  of  the  stomach  contents 
only ;  it  never  contains  bile. 

Marked  constipation  is  usually  present.  Since  the  food  does  not 
find  its  way  into  the  intestine  the  stools  are  rare  and  small. 

Emaciation  is  marked.  The  child  rapidly  loses  weight  and  pre- 
sents a  condition  of  starvation. 

The  physical  signs  are  no  less  characteristic.  Dilatation  of  the 
stomach  can  be  demonstrated  by  percussion,  and  it  will  be  found  to 
greatly  exceed  its  normal  limits.  Visible  peristalsis  is  observed 
shortly  after  taking  food.  These  peristaltic  waves  travel  across  the 
abdomen  from  left  to  right  and  are  so  vigorous  that  they  do  not 
escape  the  notice  of  the  mother  or  nurse.  This  vigorous  peristalsis 
is  pathognomonic  of  obstruction. 


FIG.  185. — DIAGRAM  OF  STOMACH  SHOWING 
THAT  ITS  TWO-FOLD  FUNCTION  is 
PLAINLY  MARKED  IN  ITS  STRUCTURE. 


494  PERITONITIS 

Pyloric  tumor  is  found  on  palpation,  usually  quite  hard,  situated 
in  the  pyloric  area  just  to  the  right  of  the  median  line.  With  this 
sequence  of  symptoms  and  physical  signs  the  diagnosis  is  unmis- 
takable. 

Treatment. — While  the  evidence  of  mechanical  obstruction  is  in- 
dubitable, yet  it  is  a  clinical  fact  that  a  number  of  children  present- 
ing these  symptoms  have  been  cured  by  medical  treatment.  It  may 
be  that  modified  function  has  some  favorable  action  upon  the  factors 
that  determine  obstruction;  and  thus  medical  treatment  may  so 
modify  the  "acid  control  of  the  pylorus"  and  the  muscular  spasm, 
that  in  a  number  of  cases  it  is  an  efficacious  means  of  cure. 

In  all  cases  it  is,  therefore,  wise  to  try  MEDICAL  TREATMENT 
first.  Hutchinson  recommends  the  following  regime: 

(1)  Regulate  the  diet  so  that  the  child  is  fed  small  quantities 
at  frequent  intervals. 

(2)  Lavage  of  the  stomach  once  or  twice  daily. 

(3)  Small  saline  enemata  (two  ounces)  twice  daily  to  make  up 
for  the  loss  of  fluids. 

If  there  is  no  improvement  in  three  or  four  weeks,  surgical 
treatment  offers  the  only  probability  of  cure. 

The  operation  of  choice  is  gastroenterostomy ;  but  it  must  be 
remembered  that  very  young  children  do  not  bear  long  intra- 
abdominal  operations  well;  hence,  the  gravity  of  the  operation  must 
always  be  prognosticated. 


CHAPTER  LIX 

PERITONITIS 

TUBERCULOUS   PERITONITIS 

Tuberculous  peritonitis  is  more  frequent  in  the  child  than  in 
the  adult.  It  is  rare  before  the  age  of  six,  and  most  frequently 
found  between  the  sixth  and  twelfth  years.  It  is  a  matter  of  com- 


TUBERCULOSIS  PERITONITIS  495 

mon  observation  that  tuberculous  peritonitis  generally  affects  chil- 
dren who  are  apparently  in  good  health  and  who  are  free  from  all 
taint  of  tuberculosis,  either  personal  or  hereditary.  In  most  cases 
tuberculous  peritonitis  is  secondary,  the  infection  being  carried  by 
the  blood  stream,  by  the  lymphatics,  or  by  direct  continuity  of 
tissues  (tuberculous  ulcer).  Clinically  the  surgeon  is  concerned 
only  with  those  chronic  manifestations  of  tuberculous  peritonitis 
which  appear  in  three  forms  corresponding  to  the  three  stages  of 
tuberculous  evolution.  It  is  obvious  that  the  dividing  line  between 
these  different  forms  is  not  sharply  defined,  but  that  they  merge  one 
into  the  other,  or  the  different  lesions  may  coexist 

Clinical  Forms. — -(a)  The  ascitic  form  is  characterized  by  the 
presence  of  serous  fluid  often  in  large  quantities ;  the  peritoneal  sur- 
face is  studded  with  minute  tuberculous  nodules.  It  is  rare  to  find 
the  bacilli  in  the  fluid  even  after  centrifugation,  but  the  inoculation 
of  guinea  pigs  with  the  fluid  usually  transmits  the  disease.  This 
form  of  ascites  may  persist  for  a  long  time;  or  it  may  be  cured 
spontaneously. 

(b)  The  fibrous  form  presents  the  process  of  a  curative  sclerosis 
and  is  so  accentuated  that  it  forms  very  large  cicatricial  masses. 
The  viscera  are  fixed  one  to  the  other  and  to  the  abdominal  wall  by 
thick  fibrous  adhesions.     These  fibrous  bands  may  contract  and  con- 
strict the  neighboring  organs,   producing  atrophy,  compression,  or 
obstruction.     Intestinal  obstruction  is  more  frequent  in  the  fibrous 
form   than   in   other    varieties    of   tuberculous    peritonitis.      These 
fibrous  masses  especially  about  the  cecum  and  in  the  great  omeutum 
may  resemble  irregular  tumors  and  be  mistaken  for  neoplasms. 

(c)  The  caseous  form  is  but  another  stage  of  the  tuberculous 
process.      Caseous    foci    are    found    among   the    fibrous    adhesions. 
Sometimes  there  are  calcareous  foci  and  little  pockets  of  pus.     The 
great  omentum  is  infiltrated  and  adherent.     The  intestinal  loops, 
inflamed  and  agglutinated,  become  friable  and  rupture  under  slight 
provocation.     The  intestines  may  even  rupture  spontaneously  and 
give  rise  to  a  fecal  phlegmon. 

Symptoms. — It  is  obvious  that  the  symptoms  vary  with  the  form 
of  the  disease.     It  runs  a  chronic  course  and  presents  a  progressive 


496  PERITONITIS 

cachexia.  There  are  emaciation,  slight  fever,  diarrhea,  abdominal 
pains,  and  slight  tenderness.  In  the  ascitic  form  the  symptoms  are 
due  to  a  gradually  increasing  quantity  of  fluid  in  the  peritoneal 
cavity.  The  abdomen  is  distended,  the  skin  tense  and  shiny,  and 
the  veins  prominent.  Sometimes  the  fluid  is  encapsulated  by 
adhesions  and  simulates  a  cystic  tumor  which  is  difficult  to  diagnose. 

In  the  fibrous  form  the  abdomen  is  slightly  distended  and  palpa- 
tion reveals  hard,  nodular  masses.  Rectal  examination  will  also 
disclose  matting  of  the  intestines  and  scattered  nodules.  In  the 
caseous  form,  or  cold  abscess  of  the  belly,  the  progress  is  more  acute 
and  the  temperature  more  irregular.  Vomiting,  diarrhea,  and 
abdominal  pains  are  more  pronounced.  Examination  of  the  abdomen 
discloses  irregular  zones  of  flatness  and  tympany.  Sometimes  the 
abscess  opens  in  the  neighborhood  of  the  umbilicus  or  perforates 
some  part  of  the  abdominal  wall  or  opens  into  the  bladder. 

Diagnosis  as  a  rule  is  not  difficult  after  carefully  observing  the 
history  and  general  findings,  with  the  assistance  of  the  v.  Pirquet 
skin  reaction,  and  injection  of  guinea  pigs  with  the  exudate. 

Treatment. — Although  it  has  been  shown  that  about  one-third  of 
all  cases  of  tuberculous  peritonitis  recover  spontaneously,  or  with- 
out operative  treatment  (Borchgrevink  and  Rose),  the  improvement 
which  follows  laparotomy  is  often  remarkable,  due  to  some  reactive 
changes  which  have  not  been  explained.  It  is  wiser,  however,  in 
these  cases  to  follow  a  conservative  course  and  at  the  onset  of  the 
disease  try  the  open-air  treatment,  aspiration,  and  X-ray  before  re- 
sorting to  laparotomy. 

If  improvement  is  not  steady  after  a  trial  of  these  measures  for 
three  months,  resort  to  operation. 

The  operation  is  simple.  The  abdomen  is  opened  in  the  median 
line  below  the  umbilicus,  and  the  straw-colored  fluid  allowed  to 
drain  away.  If  on  inspection  the  Fallopian  tube  is  found  to  be  the 
primary  focus,  it  should  be  removed.  The  wound  should  be  closed 
throughout.  No  drainage  tube  is  employed  as  it  favors  the  forma- 
tion of  a  sinus  and  in  some  cases  a  fecal  fistula. 

Judd  advises  evisceration  as  far  as  possible  and  washing  the 
intestines  with  a  fifty  per  cent,  solution  of  commercial  hydrogen 


PNEUMOCOCCUS    PEE1TONIT1S  4U7 

peroxid.  The  abdominal  cavity  is  also  thoroughly  flushed  with  the 
same  solution  and  washed  out  with  normal  saline  solution.  Chil- 
dren, however,  do  not  bear  evisceration  well  and  milder  measures 
are  advised. 

The  success  of  operation  is  more  frequent  in  the  ascitic  form 
than  in  the  fibroadhesive  form.  It  is  rare  in  the  caseous  form. 

Advanced  tuberculosis  or  amyloid  changes  in  the  lungs,  in- 
testines, or  kidney  contraindicate  operation. 


PNEUMOCOCCUS    PERITONITIS 

Pneumococcus  peritonitis  is  an  exceedingly  rare  affection  with  a 
special  predilection  for  children.  It  is  usually  observed  in  children 
between  the  second  and  twelfth  years,  and  is  much  more  frequent  in 
girls. 

It  is  a  specific  infection  of  the  peritoneum,  secondary  to  some 
preexisting  pneumococcic  lesion,  such  as  a  pleuropneumonia  or  an 
otitis  media.  The  so-called  "primary"  form  is  simply  the  use  of 
an  illogical  term  to  indicate  that  the  mode  of  infection  is  obscure. 

The  action  of  the  pneumococcus  on  serous  membranes  presents 
two  peculiarities.  It  produces  abundant  suppuration  and  a  precipi- 
tation of  considerable  fibrin,  so  that  the  suppuration  tends  to  become 
encysted.  We  note,  therefore,  that  the  cases  fall  into  two  distinct 
groups — the  encysted  and  the  diffuse  forms. 

Clinical  Forms. — (a)  The  encysted  form  is  the  clinical  type  most 
frequently  found  in  young  children.  The  encapsulated  pus  is 
generally  found  beneath  the  anterior  abdominal  wall,  in  the  median 
line,  below  the  umbilicus.  This  pus  pocket  may  increase  so  as  to 
form  an  enormous  cavity,  pushing  the  intestines  aside  and  walling 
itself  off  with  a  whitish-gray  membrane. 

The  character  of  the  exudate  is  usually  thick,  creamy,  greenish- 
yellow,  and  odorless,  and  presents  numerous  fibrin  flakes. 

(b)  The  diffuse  form  is  rarer,  more  difficult  to  recognize,  and 
the  prognosis  is  much  more  grave.  Here  there  is  no  limiting  mem- 
brane, the  pus  is  scattered  throughout  the  abdomen.  It  is  well  to 


498  PERITONITIS 

keep  in  mind,  however,  that  pneumococcus  peritonitis  is  the  least 
grave  form  of  acute  peritonitis. 

Symptoms. — In  the  encapsulated  form  the  onset  is  sudden — in- 
tense abdominal  pain,  at  first  diffuse,  and  later  centering  about  the 
umbilicus;  vomiting,  fever,  and  diarrhea  characterized  by  its  fetid 
odor.  The  general  train  of  symptoms  are  those  of  the  acute 
abdomen.  After  a  few  days  the  pain,  vomiting,  and  fever  abate, 
but  the  local  abdominal  conditions  become  more  pronounced;  the 
abdomen  is  distended  and  there  is  distinct  swelling  in  the  umbilical 
region ;  the  child  appears  cachectic.  It  is  well  to  note,  however,  that 
there  is  no  muscular  rigidity.  After  ten  or  twelve  days  the  pain  be- 
gins again,  there  are  pronounced  swelling,  fluctuation,  and  occasion- 
ally edema  of  the  abdominal  wall  in  the  region  of  the  umbilicus,  and 
if  the  process  is  not  interrupted  the  skin  is  finally  perforated  and  a 
quantity  of  pus  is  discharged.  Thus  the  progress  of  the  disease  is 
in  cycles,  recognized  by  peritoneal  invasion,  accumulation  of  pus, 
and  spontaneous  rupture. 

In  the  diffuse  form  the  onset  is  likewise  sudden — abdominal 
pain,  vomiting,  diarrhea,  and  fever;  but  the  symptoms  are  all 
accentuated,  the  prostration  is  intense,  and  death  may  occur  in  forty- 
eight  hours.  As  Stone  observes,  "the  picture  of  peritonitis  develops 
with  interesting  qualifications,  rigidity  as  a  rule  being  far  less 
marked  than  the  other  symptoms  would  seem  to  justify,  and  there 
is  diarrhea  instead  of  constipation."  The  prognosis  is  grave,  and 
the  results  fatal  unless  the  tide  is  stemmed  by  early  operation. 

Diagnosis. — It  is  evident  that  the  encysted  form  presents  a 
clinical  picture  which  simulates  appendicitis  and  with  which  it  may 
be  easily  confused. 

Note,  however,  that,  while  the  onset  is  the  same  in  the  two  affec- 
tions, in  pneumococcus  peritonitis  the  pain  is  more  diffused,  there 
is  diarrhea  rather  than  constipation,  and  the  muscular  rigidity  of 
appendicitis  is  absent.  In  tuberculous  peritonitis  the  fetid  diar- 
rhea is  rare,  the  swelling  evolutes  more  slowly,  the  lesion  is  less 
circumscribed,  the  masses  are  isolated,  and  there  is  evidence  of 
ascitic  fluid. 

In  the  diffused  form  the  diagnosis  is  always  difficult,  but  the 


PNEUMOCOCCUS    PERITONITIS  499 

indications  are  never  obscure  and  no  time  need  be  spent  upon  the 
etiology  when  the  indications  for  surgical  intervention  are  so 
apparent. 

Treatment. — The  treatment  of  either  form  is  laparotomy  and 
drainage.  The  incision  should  be  made  in  the  median  line  below 
the  umbilicus.  The  pus  is  gently  evacuated,  no  irrigation,  drainage 
tubes  are  placed  so  as  to  reach  the  deepest  possible  point.  In  the 
encysted  form  the  prognosis  is  good ;  in  the  diffuse  form  the  prognosis 
is  always  grave. 


CHAPTER  LX 

APPENDICITIS 

Appendicitis  merits  special  consideration  in  the  surgery  of  child- 
hood because  of  its  frequency,  its  obscure  symptomatology,  its 
peculiar  clinical  course,  and  its  special  rules  of  treatment. 

Appendicitis  in  the  child  differs  in  many  details  from  the  adult 
type,  because  the  child  is  more  than  a  miniature  adult.  The  child 
presents  special  characteristics  in  his  anatomical  relationships. 
There  is  a  difference  in  the  plasticity  of  the  tissues,  the  inflammatory 
reaction,  the  operative  risk,  and  the  after-treatment. 

Appendicitis  in  children  is  specially  frequent  in  the  period  be- 
tween the  fifth  and  fifteenth  years.  It  is  uncommon  before  the  fifth 
year  and  rare  in  children  under  two  years  of  age.  Boys  are  more 
frequently  affected  than  girls. 

Anatomy.' — The  vermiform  appendix  is  the  undeveloped  distal 
portion  of  the  primitive  cecum.  In  the  fetus  the  distal  portion  of 
the  cecum  ceases  to  grow  while  the  upper  portion  increases  in  size; 
hence,  at  birth  there  results  a  narrow  tube,  the  appendix,  hanging 
from  the  end  of  the  cecum  (Fig.  186).  Thus  it  is  obvious  that  the 
position  of  the  appendix  depends  upon  the  position  of  the  cecum. 
But  it  must  be  recalled  that  the  cecum  in  migrating  from  the  left 
side  of  the  abdominal  cavity  to  the  right  iliac  fossa  may  be  arrested 
in  any  part  of  its  course,  under  the  liver,  behind  the  umbilicus,  or 


500 


FIG.    186. — THE    VERMIFORM    APPENDIX. 

A.    Cecum;    B.    Vermiform    appendix;    C.    Meso- 

appendix;    D.    Appendicular    artery. 


in  front  of  the  right  kid- 
ney, and  thus  the  appen- 
dix may  occupy  any  po- 
sition in  the  abdominal 
cavity. 

Again,  the  relatively 
shorter  lumbar  region  of 
the  child  causes  the 
cecum  to  lie  at  a  com- 
paratively higher  level, 
and  thus  the  appendix  is 
situated  higher  than  Mc- 
Burney's  point. 

The  infantile  appen- 
dix is  relatively  larger  as 
compared  with  the  rest  of  the  alimentary  canal  than  in  adults,  while 
the  walls  are  much  more  delicate,  especially  the  submucous  coat.  The 
junction  of  the  appendix  with  the  cecum  is  sometimes  funnel-shaped, 
the  apex  of  the  funnel  being  continued  into  the  appendix  (Fig.  187). 
It  is  evident  that  foreign  bodies  in  this  type  of  appendix  readily 
make  their  entrance  as  well  as  their  escape. 

Drainage   is   superior  in   the   infantile    appendix   since   in   the 
smoother  mucosa  and  greater  lu- 
men there  is  less  tendency  to  the 
formation  of  valves  which  close 
its  cecal  opening. 

Finally,  it  must  be  remem- 
bered that  in  the  infant  there  is 
no  line  of  demarcation  between 
the  abdomen  and  the  pelvis.  The 
pelvis  is  but  the  cone-shaped 
terminus  of  the  abdominal  cavity. 
At  this  period  the  bladder  is  in 
greater  part  an  abdominal  organ, 
the  uterus  does  not  occupy  the 
true  pelvic  cavity,  while  the  ova- 


FIG.  187. — INFANTILE  CECUM — THE 
CONE-SHAPED  CECUM  CONTINUED 
INTO  THE  APPENDIX. 


ETIOLOGY    AND    PATHOLOGY  501 

ries  and  Fallopian  tubes  rest  in  the  iliac  fossae.  It  is  not  until  the 
child  begins  to  walk  that  there  is  any  striking  change  which  differen- 
tiates the  abdominal  and  pelvic  cavities. 

Etiology  and  Pathology. — As  already  stated,  appendicitis  is  rare 
in  children  under  two  years  of  age.  The  reason  for  this  is  evident ; 
the  smoother  mucosa  and  relatively  larger  lumen  of  the  appendix- 
give  better  drainage — there  is  less  tendency  to  retention  of  secre- 
tions ;  the  prone  position  of  the  infant  prevents  congestion ;  while 
the  simple  diet  and  fluidity  of  the  stools  render  the  intestinal  tube 
free  from  stagnation  and  fecal  concretions. 

In  older  children  the  etiology  is  the  same  as  in  adults.  Ap- 
pendicitis is  largely  a  matter  of  defective  drainage  and  defective 
structure.  When  we  consider  the  excessive  length  compared  with 
the  lumen  of  the  appendix;  the  fact  that  this  long,  narrow  tube  is 
blind  at  one  extremity,  while  at  the  other  it  communicates  with  the 
cecum — a  center  of  infectious  material ;  and  that  it  is  guarded  by 
a  valve  at  its  cecal  orifice  (the  valve  of  Gerlach),  it  is  evident  that 
if  the  appendix  is  joined  to  the  cecum  at  an  acute  angle,  or  if  the 
mucosa  in  the  neighborhood  of  the  valve  be  swollen,  there  results  a 
tube  with  both  extremities  sealed,  and  all  possibility  of  drainage 
eliminated.  Again,  the  appendix  contains  a  relatively  large  amount 
of  lymphoid  tissue  (the  "abdominal  tonsil").  This  tissue  is  of  low 
vital  resistance,  specially  prone  to  bacterial  invasion.  All  these  facts 
suggest  that  the  appendix  is  histologically  prone  to  inflammatory 
processes  since  here  we  have  a  particularly  susceptible  tissue  con- 
tiguous to  a  particularly  infectious  center. 

Intestinal  worms  are  also  important  factors  in  the  etiology  of 
appendicitis.  It  is  obvious  that  in  their  activities  they  may  cause 
an  erosion  of  the  delicate  mucosa,  which  opens  the  way  for  bacterial 
invasion. 

General  infections  play  an  important  role  in  the  causation  of  ap- 
pendicitis. It  is  not  infrequent  to  find  appendicitis  following  in  the 
wake  of  measles,  otitis  media,  influenza,  tonsillitis,  and  typhoid 
fever.  This  coincidence  is  specially  marked  in  influenza  and  gives 
it  special  etiological  significance. 

Gastrointestinal  Disorders. — Apart  from  structural  defects  and 

Lllil\;Ux\    OF 

.COLLEGE  O'r    OSTEOL= 


502  APPENDICITIS 

the  special  infections  mentioned  above,  gastrointestinal  disorders 
probably  play  the  largest  part  in  causing  appendicitis  in  children. 
Disorders  of  digestion  affect  all  parts  of  the  digestive  tube,  and  it 
may  well  be  that  appendicitis  is  but  a  localized  enteritis,  for  it  is 
significant  that  appendicitis  in  the  child  is  often  preceded  by  re- 
peated attacks  of  gastrointestinal  disorder. 

Points  of  Difference  in  the  Pathological  Process. — The  evolution 
of  appendicitis  in  the  child  presents  several  points  of  difference 
from  that  of  the  adult  type.  Appendicitis  in  children  is  not  so  fatal 
an  affection  as  in  adults  because  the  infant's  appendix  is  less  prone 
to  perforation  and  gangrene.  The  tendency  of  the  disease  in  the 
child  is  toward  the  formation  of  a  localized  abscess.  At  the  first 
onset  of  inflammation  the  omentum  promptly  offers  its  protection 
by  wrapping  itself  about  the  diseased  organ,  thus  walling  it  off 
from  the  general  peritoneal  cavity.  Hence,  unless  the  abscess  rup- 
tures, general  peritonitis  is  rare.  Not  only  is  there  found  the  pri- 
mary abscess  surrounding  the  appendix,  but,  as  the  disease  evolutes, 
secondary  abscesses  are  formed  which  may  communicate  with  the 
primary  focus  by  a  narrow  canal,  or  be  completely  separated.  This 
condition  is  notably  illustrated  in  the  secondary  pelvic  abscesses. 
The  two  foci  may  develop  simultaneously  or  the  pelvic  suppuration 
appear  after  the  iliac. 

Again,  abscess  may  appear  in  the  left  iliac  fossa  or  in  both 
fossae  at  the  same  time.  The  so-called  left-sided  appendicitis  in 
children  is  usually  a  secondary  iliac  abscess  situated  on  the  left  side. 
It  is  also  to  be  remembered  that  multiple  purulent  foci,  independent 
of  each  other,  may  become  encysted,  and,  if  the  surrounding 
adhesions  are  inadequate  for  defense,  they  may  at  any  time  rupture 
into  the  general  peritoneal  cavity  and  set  up  a  diffuse  peritonitis. 

Secondary  Complications  of  Other  Organs. — Not  only  is  there  a 
tendency  to  localized  suppuration  of  neighboring  parts,  but  to  the 
involvement  of  organs  at  a  distance, — such  as  subphrenic  abscess, 
abscess  of  the  lung,  liver,  brain,  and  parotid.  Not  infrequently 
does  a  pleural  empyema  follow  in  the  wake  of  appendicitis,  and  as 
Kelly  observes :  "It  has  happened  in  several  instances  that  a  pleural 
empyema  has  been  discovered  and  operated  upon,  while  the  pri- 


SYMPTOMS  503 

mary  cause,  a  suppurating  appendix,  has  not  been  discovered  until 
the  postmortem." 

Finally,  let  it  be  emphasized  that  the  pathological  picture,  there- 
fore, in  the  appendicitis  of  childhood  is  the  picture  of  localized 
suppuration.  It  is  this  fact  that  explains  why  the  disease  is  less 
fatal  in  childhood  than  in  adults  and  why  so  many  untreated  or 
badly  treated  cases  survive  in  spite  of  procrastinating  measures, 
which  in  the  adult  would  prove  fatal.  Mother  Nature  never  leaves 
her  children  wholly  unprotected ;  for  every  defect  there  is  some  com- 
pensatory provision ;  and  if  the  child  cannot  intelligently  articulate 
its  abdominal  distress,  yet  it  is  not  without  a  sign ;  for  the  hand- 
writing is  on  the  abdominal  wall  so  that  he  who  will  may  read. 

Symptoms. — In  considering  the  symptomatology  of  appendicitis 
in  children  the  physician  must  appreciate  that  he  is  not  dealing 
with  a  miniature  adult ;  the  child  can  neither  analyze  its  sensations 
nor  intelligently  articulate  its  distress.  There  is  no  reliable  evidence 
except  the  previous  history  as  obtained  from  the  parents  and  the 
objective  symptoms.  It  is  obvious  that  the  skilled  observer  must 
understand  the  child  nature  and  be  able  to  properly  estimate  the 
value  of  the  symptoms  under  disadvantages  which  do  not  obtain  in 
the  adult.  When  called  to  treat  a  child  with  bellyache,  vomiting, 
and  fever  proceed  at  once  to  prove  that  it  is  not  appendicitis  before 
attempting  to  prescribe.  Much  damage  has  been  done  by  the  routine 
practice  of  prescribing  for  abdominal  pain  without  making  a  care- 
ful examination  of  the  abdomen.  Get  a  careful  history  from  the 
parents  and  note  if  gastrointestinal  disorders  have  preceded  the 
attack.  They  play  an  important  role  in  the  etiology  of  appendicitis 
in  children.  Find  out  if  there  has  been  any  undue  desire  to  empty 
the  bladder  or  painful  micturition.  This  is  a  significant  prodromal 
symptom.  Next  examine  the  thoracic  viscera — an  acute  abdomen 
and  right  iliac  pain  are  often  the  first  signs  of  a  pneumonia  or 
pleurisy. 

If  the  child  is  old  enough  it  may  be  able  to  localize  its  pain  in 
the  region  of  the  appendix  and  the  physician  may  elicit  tenderness 
on  pressure  over  McBurney's  point.  With  these  two  facts  the  at- 
tention is  immediately  directed  toward  appendicitis. 


504  APPENDICITIS 

Muscular  rigidity — that  most  valuable  sign  in  adults — cannot 
be  depended  upon  in  children,  since  the  young  child  resists  any 
attempt  to  examine  the  abdomen  and  obscures  its  local  and  compara- 
tive significance  by  straining  and  putting  up  a  general  muscular 
defense. 

Cutaneous  hyperesthesia  is  often  significant  of  appendicular  in- 
flammation. A  sharp  pain  is  elicited  when  the  skin  is  lightly 
touched. 

Never  fail  to  make  a  rectal  examination  in  every  case  of  sus- 
pected appendicitis.  In  a  child,  the  palpating  finger  can  easily  ex- 
plore the  cecal  region  and  obtain  valuable  information  (Fig.  188). 
Besides,  this  method  is  more  gentle  and  less  dangerous  than  deep  pal- 


Fio.  188. — RECTAL-BIMANUAL  EXAMINATION. 

pation  from  the  outside.  //  the  child  is  intractable  these  examina- 
tions should  be  made  under  light  ether  anesthesia.  Always  remember 
in  palpating  a  child's  abdomen,  even  if  under  anesthesia,  that  gentle- 
ness is  essential,  and  that  more  than  ordinary  care  should  be  used 
in  order  not  to  rupture  the  extremely  delicate  adhesions.  When 
with  pain,  tenderness,  and  rigidity  there  is  associated  a  palpable 
mass  in  the  right  iliac  fossa,  the  diagnosis  is  no  longer  doubtful. 

The  general  symptoms  of  fever,  acceleration  of  pulse,  vomiting, 
constipation,  or  diarrhea,  are  evidences  of  toxic  absorption  and  must 
be  given  due  consideration  in  connection  with  the  local  symptoms 
described  above.  Due  regard  should  be  given  to  postural  symptoms, 
such  as  stooping  or  limping,  and  their  association  with  appendicial 
abscess  must  not  be  forgotten. 

Diagnosis. — The  diagnosis  of  appendicitis  in  children  is  either 


DIAGNOSIS  505 

simple  or  very  difficult,  depending  upon  whether  there  is  or  is  not 
a  palpable  mass  in  the  appendicular  region. 

Cases  presenting  pain  without  palpable  mass  may  ~be  mis- 
taken for: 

(a)  Acute  Indigestion. — Here  the  pain  is  general  in  character; 
there  is  no  localized  tenderness  in  the  right  iliac  fossa  or  right- 
sided  rigidity.     There  is  no  progressive  leukocytosis  and  the  acute 
symptoms  rapidly  subside. 

(b)  Typhoid  Fever. — The  onset  of  typhoid  is  slow;  the  localized 
symptoms  are  not  well  denned.      The  increase  in  the  size  of  the 
spleen  and  the  Widal  reaction  will  establish  the  diagnosis. 

(c)  Pneumonia. — If  the  thoracic  viscera  be  examined  in  every 
case  of  suspected  appendicitis,  the  results  of  auscultation  will  leave 
no  doubt  as  to  the  correct  diagnosis. 

Cases  presenting  pain  with  palpable  mass  may  be  mistaken  for: 

(d)  Intussusception. — Ileocecal   intussusception  presents   symp- 
toms that  closely  mimic  appendicitis  and  is  often  difficult  to  dif- 
ferentiate.     The  fact  that  it  occurs  in  children  with  the  greatest 
frequency  next  to  appendicitis  should  entitle  it  to  the  most  careful 
consideration.     The  onset  of  intussusception  is  marked  by  pain,  but 
not  by  fever  as  in  appendicitis.     There  is  a  discharge  of  blood  and 
mucus   from   the   rectum.      The  tumor   is   circumscribed,    sausage- 
shaped,  and  movable  transversely,  in  contradistinction  to  the  diffused 
and  immovable  mass  of  appendicitis.    (See  Intussusception,  p.  512.) 

(e)  Tuberculous    Peritonitis. — Here    the    symptoms    are    more 
diffuse.     Palpation  reveals  other  masses  than  that  in  the  iliac  fossa. 
These  masses  vary  in  size  from  small  nodules  to  large  irregular 
tumors.     Abnormal  areas  of  flatness  and  dulness  caused  by  masses 
of  adhesions   and  the   presence  of  free  fluid   ought  to   sufficiently 
differentiate  the  two  affections.     In  doubtful  cases  the  v.  Pirquet 
skin  reaction  will  be  helpful. 

Intestinal  obstruction  may  or  may  not  present  a  palpable  mass. 
Remember  that  the  onset  of  intestinal  obstruction  is  not  accompa- 
nied by  fever.  The  mechanical  phenomena  of  obstruction  alone 
mark  the  first  stage.  It  is  only  later  in  the  disease  that  there  are 
pain,  fever,  vomiting,  and  abdominal  distention.  A  leukocyte  count 


506  APPENDICITIS 

will  be  useful  in  making  an  early  differentiation  of  the  two  con- 
ditions. It  is  well  to  keep  in  mind  the  many  possibilities  which  may 
simulate  appendicitis.  Hip  disease,  urinary  calculi,  hernia,  and 
undescended  testicle,  ovarian  neuralgia,  gonorrheal  salpingitis — all 
these  should  receive  consideration  in  doubtful  cases.  The  prevalence 
of  appendicitis  has  directed  the  popular  mind  toward  a  state  of  ex- 
pectancy whenever  there  is  abdominal  pain,  and  this  in  turn  uncon- 
sciously prejudices  the  judgment  of  the  family  physician. 

Every  case  of  suspected  appendicitis  is  a  problem  which  requires 
the  surgeon's  calm  judgment  before  he  employs  the  Jcnife. 

Prognosis. — Since  prognosis  depends  upon  prompt  surgical  inter- 
vention, it  is  evident  that  the  prognosis  in  very  young  children  is 
handicapped  by  their  inability  to  describe  their  symptoms,  the 
parents'  ignorant  interpretation  of  the  attack  as  that  of  indigestion, 
and  the  physician's  difficulty  in  arriving  at  an  early  diagnosis. 

Prognosis  is  always  more  serious  in  children  under  the  age  of 
five,  and  it  is  increasingly  better  from  five  to  fifteen.  In  all  cases 
the  early  removal  of  the  appendix  insures  a  favorable  prognosis. 

Treatment. — The  treatment  of  acute  appendicitis  should  begin 
as  soon  as  appendicitis  is  suspected.  It  is  the  merest  folly  to  teach 
that  there  are  two  methods  of  treating  appendicitis, — that  the  family 
physician  is  to  carry  the  case  along  as  far  as  he  can  and  when  his 
medication  proves  futile  call  in  a  surgeon  to  inaugurate  an  entirely 
different  method  of  treatment. 

There  is  only  one  treatment  of  appendicitis ;  in  this  treatment 
the  physician  and  surgeon  each  play  an  important  role — a  role  of 
cooperation — each  bears  an  equal  responsibility,  and  each  contributes 
his  share  to  the  favorable  or  unfavorable  result.  The  results  of  the 
modern  treatment  of  appendicitis,  favorable  as  they  are,  can  never 
be  what  they  should  be  until  the  physician  and  surgeon  are  recon- 
ciled in  a  unity  of  purpose  and  uniformity  of  procedure. 

There  is  no  medical  and  surgical  treatment  of  appendicitis. 
The  treatment  is  preoperative  and  operative.  This  definitely  fixes 
the  status  of  the  physician  and  surgeon ;  the  one  prepares  the  patient 
for  operation,  the  other  performs  the  operation. 

PREOPEKATIVE  TREATMENT. — The  preparation  is  just  as  impor. 


TREATMENT  507 

tant  as  the  operation,  and  the  operative  results  will  not  improve 
until  the  surgeon  receives  the  patient  rationally  prepared. 

When  the  physician,  therefore,  suspects  appendicitis  his  further 
treatment  should  be  directed  toward  preparing  the  patient  for  opera- 
tion. That  is  putting  the  patient  in  the  best  possible  condition  to 
receive  the  benefits  of  operation.  He  must  understand  that  the  aim 
in  all  acute  abdominal  conditions  is  to  put  the  gastrointestinal  tube 
in  a  state  of  quiescence;  that  the  great  disturbing  factor  is  peri- 
stalsis, and  that  everything  that  stimulates  peristalsis  is  to  be  elimi- 
nated. The  introduction  of  food  and  the  use  of  cathartics  are  the 
two  disturbing  elements;  the  use  of  either  increases  peristalsis  and 
hence  helps  to  distribute  rather  than  localize  the  infection. 

In  the  preoperative  treatment,  therefore,  the  indications  are: 

First:    Keep  the  patient  in  bed  and  as  quiet  as  possible. 

Secojid :  Since  children  do  not  bear  well  the  deprivation  of 
nourishment  by  mouth,  give  them  that  which  creates  the  least  in- 
testinal disturbance — water  and  egg-albumin.  The  child's  nutri- 
tion will  not  be  seriously  impaired  by  this  diet,  at  least  for  twenty- 
four  hours. 

Third :  Never  prescribe  a  cathartic.  A  purge  is  the  most  deadly 
medication  that  can  be  employed  in  any  acute  abdominal  condition. 

Fourth:  Apply  an  ice-bag  to  the  abdomen.  The  sedative  effect 
of  the  ice-bag  and  its  inhibiting  effect  upon  localized  inflammations 
are  well  established. 

Fifth :  The  employment  of  small  doses  of  opium  after  the  diag- 
nosis has  been  established  quiets  the  patient  and  exerts  a  beneficent 
influence  upon  the  local  process. 

The  foregoing  preliminary  treatment  gives  the  child  its  best 
chance  in  combating  a  subtle  foe,  for  it  is  the  employment  of 
nature's  method  of  local  rest  wherever  there  is  local  inflammation. 
Furthermore,  it  gives  the  surgeon  an  assurance  that  his  problem  has 
not  been  complicated  by  a  preliminary  skirmish  that  has  only 
weakened  the  lines  of  defense;  but  that  the  physician's  viewpoint 
has  been  distinctly  surgical  from  the  very  beginning,  and  that  each 
is  contributing  his  share  to  the  solution  of  the  same  problem.  Let 
it  be  understood  then  that  the  treatment  of  appendicitis  is  distinctly 


508  APPENDICITIS 

surgical  and  that  he  who  treats  it  assumes  the  role  of  surgeon.  He 
who  practises  the  expectant  treatment  shoulders  a  large  respon- 
sibility, for  the  results  of  early  operation  in  children  are  just  as 
good  as  in  adults  and  the  threatening  phantom  of  general  perito- 
nitis casts  its  shadow  upon  every  case  unrelieved  by  operation. 

OPERATIVE  TREATMENT. — The  rule,  then,  is  to  operate  upon 
every  case  of  appendicitis  early  while  the  disease  is  confined  to  the 
appendix.  There  is  danger  only  when  the  disease  gets  beyond  the 
confines  of  the  appendix.  This  is  the  ideal  treatment  and  the  mor- 
tality is  practically  nil. 

An  important  consideration  for  the  general  practitioner,  situated 
as  he  often  is  far  from  those  skilled  in  abdominal  surgery,  is  not 
when  to  operate,  but  when  it  is  safe  to  wait.  It  is  obvious  that  no 
hard  or  fast  rules  can  be  formulated  for  a  disease  so  conspicuously 
treacherous. 

While  patients  do  recover  from  mild  attacks  of  appendicitis 
without  operation,  no  physician  can  prophesy  at  the  beginning  of 
an  attack  what  the  outcome  is  going  to  be,  and  it  must  be  remem- 
bered that  a  conservative  observing  treatment  cannot  be  inaugurated 
without  great  responsibility.  If  the  case  comes  under  the  observa- 
tion of  the  physician  three  or  four  days  after  the  initial  attack,  with 
local  and  general  symptoms  abating,  and  the  exudate  is  being  ab- 
sorbed as  shown  by  repeated  palpations  per  rectum,  operation  is  not 
indicated.  If,  however,  the  exudate  does  not  diminish  after  six  or 
seven  days,  operation  is  indicated  to  remove  the  suppurating,  focus 
and  thus  prevent  a  general  diffusion  of  the  infection  from  possible 
rupture  of  the  abscess. 

Deaver  advises  deferring  operation  "in  cases  where  there  is  a 
localizing  abscess,  with  diffuse  peritonitis,  general  abdominal  tender- 
ness, with  more  or  less  distention  and  bilateral  rigidity,  moderately 
high  temperature  and  rapid  pulse,  with  a  low  leukocyte  count  and 
a  large  percentage  of  polymorphonuclears."  Such  cases,  however, 
must  be  placed  in  the  Fowler  position  and  an  ice-bag  applied  to  the 
abdomen,  saline  is  to  be  given  by  rectum,  and  they  are  to  receive  no 
nourishment  by  mouth,  and  no  cathartics.  After  the  acute  symp- 
toms have  abated  and  the  abscess  is  well  localized,  it  is  evacuated. 


TREATMENT 


509 


It  is  evident  that  these  cases  belong  in  the  hospital,  where  the  details 
of  the  treatment  can  be  under  the  direct  supervision  of  the  surgeon. 
In   the   chronic   forms   of    appendicitis   associated   with   gastro- 
intestinal disturbance  operation  should  be  done  in  the  interval  be- 


FIG.  189. — OPERATIVE  TECHNIQUE  FOB  APPENDECTOMY. 

A,  Incision  exposing  cecum;     B,  Cecum  delivered,  and  meso-appendix  ligated;     C,  Ap- 
pendix ligated;     D,  Appendix  excised. 


tween  the  acute  attacks.     This  procedure  is  practically  free  from 
danger  and  relieves  the  patient  of  the  chronic  gastric  distress. 

THE  OPERATION  (Fig.  189).— In  early  and  interval  operations 
the  skin  incision  is  made  over  McBurney's  point  and  parallel  to  Pou- 
part's  ligament.  The  skin,  fat  and  fascia,  and  aponeurosis  of 
the  external  oblique  are  incised;  the  fibers  of  the  internal  oblique 


510  APPENDICITIS 

are  separated  by  blunt  dissection,  and  the  peritoneum  exposed  and 
opened. 

To  locate  the  appendix  it  is  well  to  remember  that  the  anterior 
longitudinal  band,  which  is  plainly  seen  on  the  anterior  surface  of 
the  colon,  leads  to  the  inferior  extremity  of  the  cecum,  at  which 
point  the  base  of  the  appendix  is  attached.  Hence,  to  find  the  ap- 
pendix, don't  search  for  it,- but  locate  the  cecum  and  the  appendix 
will  be  found  in  the  neighborhood  of  the  ileocecal  junction. 

With  two  fingers  introduced  into  the  abdominal  cavity  search 
for  the  cecum  and  draw  it  through  the  incision  so  that  it  lies  on 
the  abdominal  wall,  where  it  is  held  in  position  by  the  released 
muscles.  The  remainder  of  the  operation  is  extraperitoneal.  The 
mesoappendix  is  clamped  and  ligated ;  the  appendix  is  detached  from 
the  mesoappendix  and  its  coats  crushed  with  a  clamp  near  its  origin. 
It  is  then  ligated  and  removed.  The  stump  is  cauterized  with  car- 
bolic and  alcohol  or  sterilized  with  iodin.  The  operation  is  com- 
pleted by  suturing  the  peritoneum  and  muscular  layers  with  cat- 
gut. The  skin  and  fascia  are  closed  by  a  figure  of  eight  suture. 
The  child  may  be  allowed  out  of  bed  on  the  fifth  day  and  the 
sutures  are  removed  on  the  seventh  day  and  the  patient  discharged. 

In  appendicial  abscess  make  the  incision  over  the  most  prominent 
part.  It  is  well  to  remember  that  in  children  it  is  often  necessary 
to  drain  a  secondary  abscess  on  the  left  side,  so  that  two  incisions 
are  necessary,  one  on  the  right  and  another  on  the  left  side.  Remove 
the  pus  as  gently  as  possible  and  be  careful  not  to  tear  away  the 
protective  barriers.  The  appendix  is  removed  if  it  can  be  easily 
reached,  but  it  should  not  be  removed  if  it  endangers  the  patient's 
chances  of  recovery. 

As  a  rule  it  is  wiser  to  do  nothing  but  evacuate  the  abscess.  The 
appendix  may  be  removed  at  a  subsequent  operation. 

Place  a  rubber  drain  so  that  it  reaches  the  deepest  possible  point 
and  suture  all  the  abdominal  layers,  leaving  only  an  exit  for  the 
drainage  tube. 

Gauze  packing  should  not  be  used ;  as  a  drain  it  is  useless  and 
is  often  the  cause  of  fecal  fistula.  Fecal  fistulas  are  rare  since 
gauze  drains  have  been  abandoned.  If  the  cecal  wall  is  infiltrated, 


TREATMENT  511 

or  there  is  a  suspicious  looking  area,  it  is  well  to  pull  down  the 
omentum  and  make  an  omental  graft  over  the  dangerous  spot. 

In  Diffused  Peritonitis. — Remove  the  appendix,  the  source  of 
the  infection.  Remove  as  much  of  the  pus  as  can  be  reached 
through  the  wound  with  sponges ;  the  remainder  is  removed  by  rub- 
ber drainage  tube.  Avoid  irritation  of  the  abdominal  cavity ;  it  is 
not  only  a  futile  but  harmful  procedure  since  it  destroys  the  pro- 
tective action  of  the  peritoneum.  It  is  only  pus  under  tension  that 
is  harmful;  as  soon  as  the  tension  is  relieved  its  toxic  action  ceases. 

Close  the  abdominal  cavity  with  the  exception  of  the  exit  for 
the  drainage  tube.  By  complete  closure  of  the  abdominal  cavity  the 
normal  pressure  and  intra-abdominal  tension  conditions  are  restored. 
Thus  the  pressure  of  the  abdominal  muscles  and  the  diaphragm  not 
only  helps  to  force  the  pus  through  the  open  drain,  but  the  perito- 
neum is  prepared  to  resume  its  protective  function  under  normal 
functional  and  nutritive  conditions. 

AFTER-TREATMENT. — However  carefully  the  operation  has  been 
performed,  a  successful  issue  of  the  case  cannot  be  expected  without 
rational  after-treatment.  Two  procedures  are  of  the  utmost  im- 
portance : 

(a)  The  "Fowler  Position." — The  posture  of  the  patient  is  of 
the  utmost  importance  in  securing  proper  drainage.     As  soon  as  the 
patient  is  returned  to  his  bed  he  should  be  placed  in  the  "Fowler 
position"    (half  sitting)    to  direct  the  drainage  toward  the   pelvis 
and  prevent  further  toxic  absorption  through  the  diaphragm. 

(b)  Prevention  of  a  dangerous  lowering  of  the  blood  pressure 
by  the  introduction  of  normal  saline  solution. 

By  the  reaction  of  the  inflammation,  the  vessels  of  the  abdomen 
are  dilated ;  the  child  bleeds  into  his  abdominal  vessels ;  and,  further- 
more, the  suppuration  makes  a  great  demand  upon  the  body  fluids, 
all  of  which  contributes  to  a  dangerous  lowering  of  the  blood  pressure 
and  weakening  of  the  heart  action. 

Restoration  of  the  blood  pressure  is  admirably  accomplished  by 
the  introduction  of  normal  saline  solution  by  means  of  the  "Murphy 
drip"  (introduction  of  saline  solution  into  the  rectum  by  the  "drop 
method").  The  "Murphy  drip,"  however,  is  not  well  borne  by  chil- 


512 


INTESTIXAL  DISORDERS 


dren  because  of  their  restlessness,  and  it  is  better  to  use  small 
enemas  of  normal  saline  every  half  to  one  hour.  In  administering 
these  enemas  bear  in  mind  that  they  must  be  small  enough  to  be 
retained — not  more  than  two  or  three  ounces. 

When  vomiting  ceases  fluid  may  be  supplied  by  mouth. 

Diffused  peritonitis  operated  upon  early  by  conservative  measures 
gives  a  good  prognosis  in  children. 


CHAPTER  LXI 

INTESTINAL    DISORDERS 

INTUSSUSCEPTION 

All  forms  of  intestinal  obstruction  are  found  in  children,  but 
by  far  the  most  common  form  in  infancy  is  intussusception  or  in- 
testinal invagination.  Intussusception  is  essentially  a  disease  of 
infancy,  three-fourths  of  the  cases  being  under  two  years  of  age. 
Boys  are  more  frequently  affected  than  girls. 

Intussusception  is  the  telescoping  or  invagi- 
nation of  one  segment  of  bowel  into  the  lower 
adjoining  segment  (Fig.  190).  There  are  a 
few  instances  in  which  the  invagination  occurs 
in  the  opposite  direction — from  below  upward 
— it  is  very  exceptional. 

Intussusception  may  occur  in  any  part  of 
the  intestine,  but  in  children  the  ileocecal  re- 
gion is  the  most  frequent  site.  The  anatomical 
reason  for  this  is  evident  when  it  is  recalled 
that  the  normal  ileocecal  junction  is  really  in 
the  form  of  an  invagination.  The  usual  form 
of  intussusception  is  that  in  which  the  ileuin 
with  the  cecum  is  prolapsed  into  the  colon,  the  ileocecal  valve  form- 
ing the  apex  of  the  protrusion.  This  form  of  intussusception  may 
be  so  extensive  that  the  ileocecal  valve  may  reach  the  rectum  and  pro- 


FIG.  190. — INTUSSUS- 
CEPTION IN  VERTI- 
CAL SECTION. 

a.  Intussuscipiens;  b, 
Intussusceptum. 


INTUSSUSCEPTION  513 

trude  through  the  anus.  Note  the  mechanics  of  an  intussusception  in 
a  vertical  section.  (Fig.  190.)  It  consists  of  three  layers  of  bowel. 
The  two  inner  layers — the  intussusceptum — belong  to  the  prolapsed 
portion;  the  outer  layer — the  intussuscipiens — the  receiving  portion. 

Again,  the  two  prolapsed  layers  have  their  peritoneal  surfaces 
in  contact;  hence  the  probability  of  them  becoming  adherent.  The 
receiving  portion  and  the  prolapsed  portion  have  their  mucous  sur- 
faces in  contact. 

It  must  be  obvious  that  mechanical  intussusception  of  itself  does 
not  produce  intestinal  obstruction ;  the  obstruction  is  due  to  the 
subsequent  swelling  of  the  parts  and  the  accumulation  of  feces. 

Again,  the  prolapsed  bowel  carries  along  its  vascular  pedicle — 
the  mesentery — hence,  circulatory  disturbances  arise — venous  con- 
gestion, giving  rise  to  bleeding  within  the  bowel ;  and  arterial  con- 
striction, producing  gangrene  of  the  prolapsed  bowel,  which  may 
slough  off  and  spontaneous  cure  result,  provided  adhesions  have 
previously  been  formed  at  the  neck  of  the  intussusception. 

Symptoms. — The  onset  is  usually  sudden.  A  previously  healthy 
infant  expresses  his  agony  by  screaming  and  moving  the  legs  about 
at  intervals  of  a  few  minutes.  Between  the  pain  crises  the  child 
remains  quiet,  but  not  for  long;  the  spasms  of  pain  increase  in  fre- 
quency and  duration.  Vomiting  is  an  early  symptom  and  recurs 
frequently.-  The  pale  face,  drawn  features,  low  temperature,  and 
thready  pulse  plainly  indicate  that  the  vital  centers  ar^  profoundly 
affected. 

Note  carefully  that  obstruction  is  not  an  early  symptom  of 
intussusception — obstruction  is  secondary.  Hence,  the  child  at  first 
expels  gas  and  fecal  material — but  note  the  special  character  of  the 
material  that  is  passed  by  the  bowel — it  is  fecal  matter  in  small 
quantities  mixed  with  mucus  and  blood. 

Bloody  stools  are  characteristic  of  intussusception. 

The  blood  passed  by  rectum  is  usually  in  small  quantities,  but 
cases  are  reported  in  which  the  hemorrhage  was  so  profuse  that 
death  ensued. 

As  time  goes  on  the  patient  passes  into  a  state  of  collapse ;  con- 
stipation becomes  absolute,  and  the  abdomen  is  tympanitic. 


514  INTESTINAL  DISORDERS 

EXAMINATION  OF  ABDOMEN. — If  the  abdomen  be  palpated  early 
and  gently  it  is  usually  possible  to  detect  at  some  point  of  the 
abdomen — most  frequently  in  the  right  iliac  fossa — a  round  or 
sausage-shaped  tumor,  which  can  be  moved  transversely. 

As  the  invagination  progresses  the  tumor  increases  in  volume. 
It  is  evident  that  in  ileocecal  invagination  the  tumor  follows  the 
course  of  the  large  intestine  and  may  finally  reach  the  left  iliac 
fossa  and  the  rectum. 

EXAMINATION  OF  RECTUM. — In  all  cases  of  intestinal  obstruc- 
tion in  children  never  fail  to  make  a  rectal  examination.  This  is 
of  special  value  in  intussusception.  The  bloody  mucus  which  soils 
the  examining  finger  is  in  itself  significant,  while  if  the  invaginated 
intestine  reaches  the  rectum  the  finger  will  come  in  contact  with  a 
soft  rounded  tumor,  which  is  distinguished  from  a  rectal  polypus 
by  its  greater  volume  and  the  fact  that  it  has  no  point  of  attachment 
to  the  rectal  wall. 

If  the  invaginated  mass  protrudes  through  the  rectum  it  is  dis- 
tinguished from  a  prolapsus  ani  by  its  dark  color  and  absence  of 
pedicle. 

Where  spontaneous  cure  occurs,  which  is  rare,  a  fetid  diarrhea 
marks  the  expulsion  of  the  sloughing  intussusceptum. 

Diagnosis  should  not  be  difficult  if  we  keep  in  mind  the  cardinal 
symptoms — sudden  onset,  violent  intermittent  pain,  bloody  stools, 
and  tumor;  and  the  additional  fact  that  invagination  is  the  most 
frequent  cause  of  intestinal  obstruction  in  very  young  children 
(under  age  of  two).  In  infants  it  is  differentiated  from  enterocolitis 
by  the  presence  of  a  tumor,  the  profound  collapse,  and  bloody  stools. 
It  is  differentiated  from  appendicitis  by  the  absence  of  fever,  the 
more  circumscribed  tumor,  mobility  of  the  tumor  transversely,  and 
bloody  stools. 

The  fate  of  the  patient  depends  upon  early  diagnosis. 

Prognosis. — After  diagnosis  has  been  made  only  radical  removal 
of  the  pathological  condition  can  give  relief. 

It  must  be  remembered  that  results  are  good  only  when  the  opera- 
tion is  done  in  the  first  twelve  hours.  Furthermore,  it  is  not  pos- 
sible from  the  symptom-complex  to  get  an  adequate  idea  of  the 


INTUSSUSCEPTION  515 

severity  of  the  anatomical  changes,  and  the  only  rational  remedy  is 
immediate  exposure  of  the  invaginated  part. 

Treatment. — Never  prescribe  a  cathartic  in  any  acute  abdominal 
condition — only  damage  is  done  in  intestinal  obstruction  by  pre- 
scribing cathartics.  A  purge  is  a  deadly  measure  in  intussusception. 
Never  prescribe  opium  until  the  diagnosis  has  been  made  and  prep- 
arations for  operation  begun. 

METHOD  OF  PROCEDURE. — After  complete  preparation  for  opera- 
tion is  made: 

First:  Try  bloodless  reduction  as  follows: 

Give  the  patient  light  ether  narcosis  to  relax  the  abdominal  wall. 

Make  a  careful  bimanual  examination  per  rectum. 

Endeavor  to  reduce  the  invaginated  intestine  by  distention  with 
water. 

Introduce  saline  at  body  temperature  per  rectum  by  means  of  a 
soft  rubber  catheter  and  a  funnel  held  about  three  feet  above  the 
patient.  The  patient's  pelvis  is  elevated  and  the  glutei  pressed 
closely  together  to  prevent  the  return  of  the  liquid.  With  the 
abdomen  relaxed  by  narcosis  any  changes  in  the  tumor  are  easily 
recognized  by  means  of  palpation. 

If  the  surgeon  is  successful  the  patient  should  be  put  to  bed  and 
given  a  dose  of  opium  to  prevent  the  invagination  from  returning. 
This  method  of  reduction  has  the  same  relation  to  intussusception 
as  taxis  has  to  strangulated  hernia.  It  also  has  the  same  limitations. 

Second:  If  irrigation  leads  to  no  disinvagination,  immediate 
opening  of  the  abdomen  should  follow. 

The  tumor-mass  should  be  brought  forward  and  all  eventration 
and  chilling  of  the  intestines  avoided,  as  the  shock  is  fatal  to  chil- 
dren. The  invaginated  part  is  wrapped  •  in  hot  towels  and  kept 
extraperitoneal.  The  other  loops  of  bowel  are  replaced. 

The  method  of  loosening  the  invaginated  gut  is  very  important. 
Never  pull  out  the  invaginated  part  because  of  the  danger  of  tear- 
ing the  gut.  Try  and  push  out  the  invaginated  part  slowly  and 
gently.  If  manual  reduction  of  the  invagination  is  impossible  then 
resection  must  be  considered.  But  remember  that  manual  reduction 
should  be  done  if  possible,  for  it  is  easier  to  save  a  child  even  with 


516 


INTESTINAL  DISOEDEES 


a  slight  laceration  of  the  serosa,  which  can  be  patched  with  omentum, 
than  to  subject  it  to  resection. 

.  The  technique  of  resection  varies  with  the  location  of  the  lesion 
and  the  general  rules  of  abdominal  surgery  apply. 


CONGENITAL   IDIOPATHIC    DILATATION    OF    THE    COLON 

(Hirschsprung's  Disease) 

This  condition  has  been  termed  "giant  colon"  and  is  character- 
ized by  an  enormous  dilatation  of  the  colon  for  which  no  mechanical 
or  specific  cause  can  be  found.  The  disease  is  usually  observed  in 
young  children,  who  are  brought  to  the  physician  on  account  of 
obstipation. 

Symptoms. — The  symptoms  are  observed  soon  after  birth,  and 
the  history  given  by  the  parent  shows  that  the  child's  bowels  have 

never  moved  normally ; 
that  a  movement  of  the 
bowel  is  not  possible 
without  the  use  of  an 
enema.  These  cases  go 
for  weeks  without  a 
bowel  movement,  then 
for  a  day  or  two  there 
will  be  many  large  move- 
ments of  foul  feces,  to  be 
followed  again  by  weeks 
of  constipation  (Judd). 
The  disease  is  more  com- 
mon in  boys  than  in  girls, 
and  is  characterized  by  a 
condition  of  extreme  de- 
bility and  emaciation. 
The  development  of  the 
body  is  retarded  by  mal- 


FIG.  191. — CONGENITAL  IDIOPATHIC  DILATATION  OF 
THE  COLON.  (Escherich's.  Case.) 


IMPERFORATE    ANUS    AND    RECTUM  517 

nutrition  and  autointoxication,  while  in  striking  contrast  is  the 
greatly  distended  abdomen.  (Fig.  191.) 

It  is  evident  that  the  greatly  distended  colon  presses  the  dia- 
phragm upward,  encroaches  upon  the  thoracic  cavity  and  its  viscera, 
so  that  respiration  is  embarrassed  and  the  heart  function  impaired 
by  displacement. 

Treatment. — Surgery  offers  the  only  permanent  relief  for  these 
cases,  since  nutritional  equilibrium  cannot  be  established  so  long  as 
the  dilated  colon  acts  as  a  fecal  reservoir  that  cannot  be  normally 
emptied. 

Operation  necessitates  the  elimination  of  the  diseased  colon  and 
an  anastomosis  of  the  ileum  and  rectum.  The  technique  of  the 
resection  and  anastomosis  is  the  same  as  in  the  adult. 

It  must  be  remembered,  however,  that  the  long  duration  of  the 
operation  and  the  narcosis  is  dangerous  to  the  child.  It  is  essential 
therefore  that  the  operation  be  as  simple  and  speedy  as  possible. 
All  eventration  and  chilling  of  the  intestines  should  be  avoided;  all 
manipulations  should  be  done  extraperitoneally,  and  the  vitality  of 
the  peritoneum  should  be  carefully  conserved. 


CHAPTEK  LXII 

DISEASES    OF    THE    ANUS    AND    EECTUM 

IMPERFORATE  ANUS  AND  RECTUM 

There  are  many  curious  developmental  defects  of  the  rectum  and 
anus,  such  as  absence  of  the  rectum  or  anus,  or  both,  and  again, 
the  opening  of  the  rectum  at  some  unusual  point,  such  as  the  blad- 
der, deep  urethra,  and  vagina. 

The  most  common  congenital  defect  of  the  rectum  is  imperf 'orate 
anus,  occurring  most  frequently  at  the  anorectal  junction.  The 
reason  for  this  defect  is  apparent.  The  rectum  and  anal  canal  are 
developed  independently  of  each  other.  The  rectum  is  developed 
from  the  terminal  extremity  of  the  hind-gut,  the  anal  canal  by  an 


518 


DISEASES  OF  THE   ANUS  AND  RECTUM 


invagination  at  the  site  of  the 
anus,  the  septum  between  the  two 
being  normally  absorbed  and  a 
continuous  canal  formed.  Fail- 
ure of  this  partition  to  absorb  re- 
sults in  imperforate  anus.  The 
occlusion  may  consist  of  a  thin 
membrane,  which  is  readily  in- 
cised, or  it  may  attain  consider- 
able thickness,  requiring  more  ex- 
tensive operation  to  obtain  relief 
and  establish  a  permanent  canal. 
Absence  of  the  anus  is  very 
FIG.  192.— ABSENCE  OF  ANUS;  RECTUM  rare  (Fig.  192).  There  is  USU- 

JSch.'T0  IN  A   BLIND  P°UCH'    a11?    a     closed    but    well-formed 

anus.  If  the  anus  is  not  devel- 
oped the  sphincter  ani  does  not  exist,  and  therefore  when  the  rectum 
is  brought  out  through  the  perineum  incontinence  follows.  If  the 
anus  is  closed  but  normally  formed  it  is  usual  to  get  continence 
after  operation. 

Clinical  Picture.  — It  is  obvious  that  the  clinical  picture  of  im- 
perforate anus  is  that  of  intes- 
tinal obstruction.  It  is  observed 
shortly  after  birth  that  there  is 
no  escape  of  meconium,  the  child 
does  not  soil  the  diaper.  There 
are  restlessness  and  vomiting,  the 
child  refuses  the  breast,  the 
urine  is  scanty,  and  the  skin 
jaundiced ;  the  abdomen  distends, 
and  unless  there  is  successful  in- 
tervention there  are  general  tox- 
emia and  death. 

The  fact  that  the  child  does 
not  soil  the   diaper  is  the   first 

FIG.      193. — NORMAL     ANUS     WITH    ANO- 
intimation    that    there    is    an    OC-  RECTAL  SEPTUM.  (Froelicb.) 


IMPERFORATE    ANUS    AND   RECTUM 


519 


elusion  of  the  rectum,  and  an  examination  should  be  immediately 
made  to  establish  a  diagnosis.  The  child  should  be  placed  on  its 
back  and  the  parts  thoroughly  exposed  so  that  the  anus  may  be 
examined  with  the  greatest  care.  If  the  anus  is  occluded  by  a  thin 
membrane,  the  greenish  color  of  the  meconium  can  be  seen  through 
the  transparent  membrane,  which  also  balloons  out  when  the  child 
cries. 

Again  the  anus  may  be  normal,  but  there  may  be  an  anorectal 
septum  occluding  the  passage  (Fig.  193).  No  examination  is  com- 
plete without  passing  a  sound  to  prove  the  condition  of  the  anorectal 
tube.  Finally  the  anus  may  be  absent  and  there  be  no  bulging  of  the 
perineum  when  the  child  cries,  so 
that  there  is  no  intimation  of  the 
depth  at  which  the  bowel  is  oc- 
cluded. It  is  obvious  that  in  these 
cases  the  prognosis  is  extremely 
unfavorable. 

Examine  the  urogenital  re- 
gion for  external  fistulse  that 
communicate  with  the  bowel. 
These  openings  are  apt  to  be 
situated  on  the  under  surface  of 
the  penis  or  skin  of  scrotum; 
in  the  female,  examine  the  pos- 
terior wall  of  the  vagina  and  the  vulva.  (Fig.  194.) 

It  is  obvious  that  those  cases  where  there  is  a  total  or  partial 
communication  with  the  bladder  give  the  worse  prognosis,  since  in- 
fection of  the  urinary  tract  is  inevitable.  If  the  urine  is  sometimes 
clear,  and  at  other  times  mixed  with  feces,  there  is  a  communication 
with  the  urethra.  If  the  urine  is  always  mixed  with  feces  the  com- 
munication is  probably  with  the  bladder. 

Treatment. — Operation  is  necessary  to  restore  the  normal  ana- 
tomical conditions.  The  time  of  operation  depends  upon  the  gravity 
of  the  malformation.  Fistulous  communications  can  wait,  but  the 
removal  of  a  total  obstruction  is  an  urgent  operation  and  must  be 
relieved  as  speedily  as  possible. 


FIG. 


194. — RECTUM    TERMINATING    IN 
THE  VAGINA. 


520  DISEASES   OF  THE   ANUS  AND   EECTUM 

(1)  If  the  obliteration  of  the  rectum  is  due  to  a  thin  bulging 
membrane,  do  not  be  content  with  a  simple  puncture.     Place  the 
infant  in  the  lithotomy  position,  so  that  the  perineum  is  well  ex- 
posed.    Make  a  crucial  incision  in  the  membrane.     After  the  in- 
testine is  completely  emptied,  wash  out  the  rectum,  excise  the  tags 
of  membrane,  and  suture  the  mucosa  to  the  skin. 

(2)  If  the  rectum  is  more  or  less  distant  from  the  perineum 
and  does  not  bulge  when  the  infant  cries,  it  is  necessary  to  search 
for  the  rectum  by  way  of  the  perineum.     Give  light  ether  anesthesia 
and  place  the  infant  in  the  lithotomy  position.     Make  a  median 
incision  through  the  anal  dimple  (when  the  anus  is  present  cut  the 
sphincter  only  once — posteriorly)   and  dissect  carefully  toward  the 
anterior  surface  of  the  sacrum.     Take  care  not  to  wound  the  blad- 
der in  front.     It  can  be  easily  identified  by  previously  inserting  a 
catheter.    Proceed  carefully  along  the  anterior  surface  of  the  sacrum, 
where  the  rectum  must  be  found.     After  the  ampulla  of  the  rectum 
is  identified  by  its  bluish  appearance,  do  a  blunt  dissection  with  the 
finger  to  separate  it  from  the  neighboring  organs  and  mobilize  it 
so  as  to  bring  it  down  and  forward  to  the  surface  of  the  skin.     Be 
careful  to  avoid  any  violent  traction  which  might  burst  the  distended 
bowel.     Carefully  tampon  the  wound  with  gauze,  then  incise  and 
evacuate  the  contents  of  the  bowel.     After  the  wound  has  been  thor- 
oughly irrigated  suture  the  lips  of  the  incised  rectum  to  the  skin 
with  sutures  that  traverse  the  entire  thickness  of  the  rectal  wall 
and  close  the  deep  wound  with  figure-of-eight  sutures.      An   anus 
thus  formed  has  a  tendency  to  contract,  so  that  it  is  necessary  to 
dilate  with  a  sound  every  day. 

(3)  If  the  rectum  cannot  be  found  as  far  as  the  promontory  of 
the  sacrum,  do  a  left-sided  laparotomy  and  through  this  opening 
endeavor  to  push  the  rectum  toward  the  perineal  wound.     If  this 
procedure  fails  make  an  artificial  anus  (inguinal  colostomy). 

The  mortality  of  operations  for  anorectal  occlusions  is  very  high. 
They  are  satisfactory  only  when  the  sphincter  is  present. 

(4)  Operative  intervention  for  abnormal  openings  of  the  bowel 
is  less  urgent.     These  cases  are  bad  surgical  risks  and  operation 
should  be  avoided  until  the  vital  index  is  sufficiently  high.      No 


PROLAPSE    OF    THE    RECTUM 


521 


formal    operations    are    applicable   to   these    cases.      They    tax    the 
ingenuity  of  the  surgeon,  and  each  case  is  a  law  unto  itself. 


PROLAPSE    OF    THE    RECTUM 

Prolapse  of  the  rectum  is  a  protrusion  of  the  mucous  membrane 
of  the  rectum  or  of  the  entire  rectal  wall  through  the  anus.  Thus 
there  may  be  a  "partial"  or  "total"  prolapse,  and  the  distinction 
between  the  two  is  not  the  length  but  the  thickness  of  the  prolapse. 

"Partial"  prolapse  is  a 
protrusion  of  the  anal  mu- 
cosa  through  the  anal  orifice. 
(Fig.  195.)  It  may  return 
spontaneously  after  the  effort 
of  defecation  which  caused 
its  expulsion.  It  is  due  to  a 
relaxation  of  the  cellular  tis- 
sue which  holds  the  mucosa 
to  the  muscular  coat  of  the 
anus. 

"Total"  prolapse  is  a 
protrusion  of  the  entire  rec- 
tal wall,  caused  by  a  relaxa- 
tion of  the  tissues  which  hold 
the  rectum  in  place  and  by 
an  increase  in  the  intrapelvic 
pressure  to  which  the  rectum 
is  exposed. 

It  is  a  significant  anatomical  fact  that  the  great  majority  of 
cases  of  rectal  prolapse  occur  between  the  first  and  third  years, 
when  the  erect  posture  is  in  the  developmental  stage,  while  physio- 
logical lordosis  is  as  yet  incomplete  and  the  sacral  curve  is  still 
shallow. 

The  rectum  not  sufficiently  adapted  to  the  upright  position; 
the  pelvic  floor  relaxed  by  the  atrophy  of  malnutrition  and  lack  of 
muscular  tone;  the  increased  intra-abdominal  pressure  caused  by 


FIG.  195. — PROTRUSION  OF  THE  ANAL  MUCOSA 

THROUGH    THE    ANAL    ORIFICE.     (Spitzy.) 


522 


DISEASES  OF  THE   ANUS  AND  RECTUM 


straining  at  stool  in  the  sitting  posture  are  factors  which  contribute 
to  the  descent  of  the  bowel  through  the  anal  outlet.  Furthermore, 
such  affections  as  chronic  diarrhea,  whooping  cough,  phimosis, 
vesical  calculus,  polypus  of  the  rectum,  all  of  which  increase  intra- 
abdominal  pressure  by  causing  undue  and  prolonged  straining,  play 
an  important  pathogenic  role  in  the  production  of  rectal  prolapse. 
For  rectal  prolapse  finally  represents  the  unequal  struggle  between 
the  rectal  tissues  and  the  propulsive  force  which  is  necessary  to 
expel  the  rectal  contents. 

Symptoms. — Inspection   reveals    a   rosette   of  mucous   membrane 

covered  with  glairy  mucus  sur- 
rounding the  anus,  with  an  orifice 
at  its  summit.  Usually  it  can  be 
easily  reduced  after  defecation. 

If  the  entire  rectum  is  pro- 
lapsed we  observe  an  elongated 
flabby  tube  curved  backward.  The 
orifice  at  its  summit — the  lumen  of 
the  intestine — is  elliptical  and  flat 
transversely.  The  color  of  the  pro- 
lapse is  a  violet  red.  If  it  remains 
for  a  long  time  exposed,  it  swells, 
bleeds,  and  presents  areas  of  ul- 
ceration  with  a  grayish  base. 

It  is  evident  that  the  protruding 
rectal  mass  is  composed  of  two  portions  of  the  rectal  tube  with  their 
serous  coats  in  contact  (Fig.  196),  and  that  between  the  internal  and 
external  cylinders  there  is  a  potential  pouch  in  which  loops  of  intes- 
tine may  occasionally  engage.  This  form  of  hernia  is  known  as 
hedrocele.  If  the  prolapse  is  continuous  there  are  pain,  constant  loss 
of  blood,  ulceration,  and  infection,  which  seriously  imperil  the 
child's  existence. 

Diagnosis. — There  are  few  lesions  that  can  be  confounded  with 
rectal  prolapse — only  two  are  liable  to  confuse: 

(a)   Rectal  polypus,  which  is  a  small  tumor  and  permits  the 
introduction  of  the  finger  between  its  pedicle  and  the  rectal  wall. 


FIQ.  196. — PROLAPSE  OF  THE  RECTUM. 


PROLAPSE    OF    THE    RECTUM  523 

(b)  Intestinal  imagination,  which  presents  the  general  symp- 
toms of  intestinal  obstruction,  and  permits  the  examining  finger  to 
sweep  around  between  the  tnmor  and  the  rectal  wall. 

Prognosis. — If  the  child  is  properly  watched  and  treated  up  to 
the  fifth  year  the  prolapse  may  disappear  spontaneously  unless  pre- 
vented by  congenital  causes  or  by  tumors.  If  the  prolapse  is  not 
kept  reduced  the  sphincter  and  muscular  floor  may  be  so  weakened 
and  stretched  that  permanent  reduction  is  impossible. 

Treatment. — The  tendency  of  this  disturbance  is  toward  spon- 
taneous cure  and  a  cure  can  be  obtained  in  a  large  number  of  cases 
by  removing  the  etiological  factors  and  keeping  the  prolapse  reduced. 
When  all  digestive  disturbance  is  stopped,  and  the  child  is  placed 
under  proper  hygienic  conditions,  when  all  conditions  causing 
abdominal  pressure  are  suppressed  and  straining  at  stool  is  avoided, 
the  tendency  to  prolapse  will  soon  vanish. 

PREVENTING  THE  EXTRUSION  BY  MECHANICAL  MEANS. — The 
cure  consists  in  preventing  the  extrusion.  The  indications,  then, 
are  first  to  remove  all  contributory  causes  and  then  to  reduce  the 
prolapse  and  keep  it  reduced.  Persistent  care  will  obviate  the 
necessity  of  operative  procedures. 

Method. — If  the  sphincter  has  not  entirely  lost  its  tonicity  the 
following  procedure  will  result  in  curing  a  large  majority  of  cases. 
Place  the  child  on  the  lap  face  down,  and  raise  the  legs  so  as  to 
get  the  assistance  of  gravity.  Anoint  the  prolapse  with  vaselin  and 
grasp  it  by  the  four  fingers.  Gently  compress  the  prolapse  so  as 
to  reduce  its  volume  and  push  it  in  the  anal  orifice.  Further 
extrusion  of  the  prolapse  is  now  prevented  by  placing  two  adhesive 
straps  across  the  buttocks  so  as  to  hold  them  firmly  together  and 
thus  support  the  anal  muscle.  After  each  defecation  the  parts  are 
cleansed,  and  protrusion  reduced,  and  the  straps  renewed.  It  is 
evident  that  this  treatment  must  be  repeated  several  times  a  day, 
and  the  mother  or  nurse  must  be  instructed  accordingly. 

REDUCTION  OF  PROLAPSE  BY  OPERATION. — If  the  prolapse  has 
continued  for  a  long  time,  so  that  the  sphincter  has  lost  its  tonicity, 
and  reduction  cannot  be  maintained,  operation  is  indicated.  Many 
operations  have  been  devised  which  undoubtedly  give  excellent  re- 


524  DISEASES  OF  THE   AXUS  AXD  RECTUM 

suits  in  the  adult,  but  these  operations  are  too  severe  for  children, 
and  the  simpler  procedures  should  always  be  chosen. 

(a)  Cauterization. — Light  ether  anesthesia;  preparatory  purga- 
tive and  cleansing  enema.     The  paquelin  cautery  is  drawn  along 
the  mucous  membrane  lengthwise  of  the  bowel.     The  whole  thickness 
of  the  mucosa  is  seared  (not  the  muscularis)  at  four  points,  in  front, 
behind,  and  on  each  side.     The  operation  is  completed  by  inserting 
into  the  rectum  a   rubber  tube  wound   with  iodoform   gauze   and 
smeared  with  vaselin.     The  after-pain  is  controlled  by  small  doses 
of  opium  and  the  bowels  are  kept  constipated  for  a  week. 

As  the  scars  heal  the  resulting  cicatricial  bands  contract  and 
hold  the  mucosa  in  good  position. 

(b)  Spitzy's  Method  of  Paraffin  Injection. — The  prolapse  is  re- 
duced and  treated  until  the  mucosa  is  free  from  excoriations.     Under 
light  ether  narcosis,  and  with  careful  disinfection  of  the  anal  region, 
the   author  introduces    into   the   pararectal   tissue   by   means   of    a 
syringe  holding  5  c.  c.  two  pencil-like  splints  of  paraffin. 

The  point  of  the  filled  syringe  is  inserted  one  centimeter  above 
the  anal  orifice  and  pushed  into  the  pararectal  tissue  about  two  and 
a  half  inches  under  control  of  the  finger  inserted  into  the  rectum 
and  without  encroaching  upon  the  mucous  membrane.  The  injec- 
tion is  made  as  the  syringe  is  slowly  withdrawn  and  stops  just  be- 
fore the  point  of  entrance  is  reached.  In  this  manner  a  rapidly 
hardening  pencil-like  splint  is  formed  and  repeated  on  the  opposite 
side.  After  the  injection  the  buttocks  are  firmly  strapped  with 
adhesive  plaster  for  two  days.  After  the  first  normal  defecation 
the  children  are  discharged.  Thirty-two  cases  with  only  one  failure 
are  reported  by  Spitzy.  The  writers  have  had  no  personal  experience 
with  this  method  but  the  excellent  results  reported  are  worthy  of 
consideration. 

(c)  Formal  Operations. — Such  as  are  designed  to  fix  the  rectum 
at  a  higher  level   (rectopexy,  colopexy,  etc.)   have  no  place  in  the 
surgery  of  childhood.     If,  however,  the  prolapse  is  of  long  duration 
and  its  dimensions  are  such  that  reduction  cannot  be  considered, 
amputation  of  the  prolapse  is  demanded. 

After  careful  disinfection,  grasp  .the  prolapsed  mass  with  a  wet 


POLYPUS    OF    KECTUM  525 

bichlorid  towel,  and  cautiously  make  an  incision  transversely  across 
the  mass  a  finger's  breadth  below  the  anal  margin.  Look  out  for 
intestinal  coils  in  the  peritoneal  pouch  between  the  two  coats  of  the 
prolapsed  gut.  Close  off  the  peritoneal  cavity  by  suturing  together 
the  serous  surfaces  as  the  incision  is  extended.  After  the  external 
tube  is  entirely  divided,  the  internal  tube  is  excised  just  in  front 
of  the  line  of  sutures  already  applied  and  the  cut  edge  clamped 
with  forceps  to  prevent  retraction.  The  second  row  of  sutures  is 
now  applied,  including  all  the  coats  of  the  gut.  The  stump  is 
cleansed  and  returned  and  the  bowel  is  kept  constipated  for  a  week. 


POLYPUS  OF  RECTUM 

Rectal  polypi  are  benign  tumors  with  a  pedicle,  implanted  on 
the  posterior  rectal  wall.  The  character  of  the  polypi  found  in 
children  are  true  adenomata ;  they  are  soft,  usually  single,  about  the 
size  of  a  cherry,  and  of  a  dark  red  color. 

These  tumors  are  at  first  sessile,  but  little  by  little  as  the  tumor 
drags  on  the  mucous  membrane  a  pedicle  is  formed.  This  pedicle 
may  rupture  and  the  tumors  be  expelled  spontaneously.  The  pedicle 
is  rarely  implanted  higher  than  one  and  a  half  to  two  inches  above 
the  anus. 

Etiology. — The  etiology  of  polypus  of  the  rectum  is  a  matter  of 
conjecture;  we  only  know  that  it  is  an  affection  specially  frequent 
in  children  between  the  second  and  fourth  years  and  that  it  is  a 
factor  in  causing  prolapsus  of  the  rectal  wall. 

Symptoms. — Painful  defecation,  frequent  desire  to  go  to  stool, 
straining  efforts  at  stool,  the  frequent  presence  of  blood  or  of  bloody 
mucus  in  the  stools,  vesical  tenesmus,  and  anemia.  The  staining 
of  the  napkin  with  blood  gives  the  parents  the  impression  that  the 
child  is  suffering  from  hemorrhoids. 

Diagnosis.- — The  passing  of  blood  with  the  stools  should  immedi- 
ately suggest  polypus  of  the  rectum,  and  a  rectal  examination  should 
be  made.  The  rectal  touch  permits  us  to  recognize  the  pedunculated 
tumor,  which  may  often  be  drawn  out  of  the  anus.  But  the 


526  DISEASES  OF  THE   ANUS   AND- RECTUM 

pedicle  should  not  be  ruptured,  as  it  may  cause  considerable  hemor- 
rhage. If  a  satisfactory  examination  cannot  be  made  with  the 
finger  a  speculum  may  be  of  service. 

Treatment. — Extirpation  of  the  polypus  is  easily  effected  by 
passing  a  ligature  around  the  pedicle  and  excising  the  tumor  with 
scissors.  If  the  pedicle  is  short  it  may  be  necessary  to  anesthetize 
and  practise  forcible  dilatation  of  the  anus  preliminary  to  ligation 
and  excision. 

FISSURE    OF    THE    ANUS 

Fissure  of  the  anus  consists  of  a  small  crack  or  loss  of  substance 
in  the  mucosa  of  the  anal  margin.  It  is  really  an  intrasphincteric 
erosion  hidden  in  the  folds  of  the  anus  usually  lying  on  the  posterior 
wall.  It  is  originally  due  to  a  superficial  tear  in  the  mucosa,  caused 
by  the  passage  of  a  too  large  or  too  hard  fecal  bolus. 

Rarely  it  is  caused  by  the  mechanical  obstruction  of  a  polypus 
or  the  irritation  of  an  enterocolitis.  As  a  rule  the  child  suffering 
from  anal  fissure  is  a  constipated  child. 

Symptoms. — Sharp  pain  at  time  of  defecation,  slight  loss  of  blood, 
and  spasmodic  contraction  of  the  sphincter.  Constipation  may  be 
the  initial  cause,  or  it  may  be  voluntary  on  the  part  of  the  child 
because  of  the  fear  of  pain.  Whenever  a  child  has  a  constipated 
movement  with  pain  and  some  loss  of  blood  our  attention  should  be 
directed  toward  anal  fissure,  and  an  examination  should  be  made 
with  this  condition  in  view. 

Hilton  has  called  attention  to  the  fact  that  the  same  nerves 
which  supply  the  mucous  membrane  supply  the  muscular  apparatus 
acting  upon  that  membrane.  Observe  how  this  law  is  corroborated 
in  fissure  of  the  anus.  The  exposure  of  the  sensory  nerve  filaments 
on  the  ulcer  surface  causes  reflex  spasmodic  contraction  of  the 
sphincter.  As  the  sphincter  contracts,  it  squeezes  the  sensitive  edges 
of  the  ulcer;  in  course  of  time  the  sphincter  hypertrophies  and  the 
symptoms  which  at  first  appeared  for  a  short  time  after  stool  are 
later  prolonged  from  one  stool  to  another. 

Again,  the  anal  canal  and  the  neck  of  the  bladder  are  intimately 


PEEIANAL    ABSCESS  527 

associated  through  their  nerve  supply,  hence,  fissure  of  the  anus  is 
often  accompanied  by  retention  of  urine. 

Not  only  this  but  the  pelvic  viscera  and  the  thigh  and  leg  are 
intimately  associated  in  their  nerve  supply  through  the  sacral  plexus, 
hence  anal  fissure  is  sometimes  associated  with  muscular  contrac- 
tures  of  the  thigh  accompanied  by  pain  in  the  hip  and  knee — a 
picture  simulating  coxalgia. 

In  very  young  children  fissure  of  the  anus  is  rarely  recognized; 
whenever,  therefore,  there  is  painful  defecation,  a  rectal  examination 
should  be  made.  To  do  this  satisfactorily  light  ether  anesthesia 
should  be  employed. 

Treatment.- — The  prime  indication  is  to  remove  the  constipation 
by  mild  laxatives. 

Locally,  good  results  may  be  obtained  by  applying  directly  to 
the  fissure  a  ten  per  cent,  solution  of  nitrate  of  silver  or  cocain  oint- 
ment. If  these  measures  fail  the  sovereign  remedy  is  forcible  dila- 
tation of  the  sphincter  under  light  ether  narcosis. 

The  operator  inserts  both  thumbs  and  gently  dilates  the  anal 
ring  until  the  muscle  is  thoroughly  relaxed. 

After  operation  the  patient  should  be  kept  in  bed  for  two  or 
three  days  and  given  a  light  diet  for  easy  defecation. 


PERIANAL   ABSCESS 

Abscesses  pf  the  perianal  region  are  rare  in  children.  The 
entrance  of  the  infection  is  through  a  preexisting  fissure  or  through 
a  recent  wound  of  the  anorectal  mucosa,  sometimes  due  to  the  use 
of  the  rectal  thermometer  or  to  foreign  bodies  from  the  intestine. 
In  certain  cases  they  are  secondary  to  an  osteomyelitis  of  the  pubis. 

Symptoms. — Whatever  the  cause,  these  abscesses  have  a  common 
symptomatology — at  the  onset  there  are  high  fever  and  pain  at  the 
time  of  defecation.  Later  there  is  a  hard  diffuse  swelling  about  the 
anus,  which  later  softens  and  opens  spontaneously,  discharging  a 
quantity  of  pus  and  blood. 


528 


SARCOMA  OF  THE  KIDNEY 


In  rare  instances  there  may  be  urinary  disturbances  due  to 
compression  of  the  urethra. 

Treatment. — Early  incision  as  soon  as  the  abscess  is  recognized 
to  prevent  spreading.  The  incision  should  extend  into  the  anal 
opening  to  secure  a  rapid  cure  and  prevent  the  formation  of 
fistulse. 


I 


CHAPTER  LXIII 

SAECOMA    OP    THE    KIDNEY 

As  cancer  is  the  malignant  disease  of  old  age,  so  sarcoma  is  the 
malignant  disease  of  infancy.  Its  relation  with  the  embryonal 
building  material  has  some  probable  bearing  upon  its  relative  fre- 
quency in  the  child's  organism.  Sarcoma  of  the  kidney  is  found 
quite  frequently  in  children  during  the  first  decade. 

It  merits  special  men- 
tion because  of  its  insidious 
onset  and  the  enormous 
proportions  that  the  tumor 
may  attain.  As  a  rule, 
when  the  surgeon  sees  these 
cases  the  tumor  has  ac- 
quired a  volume  that  makes 
intervention  impossible. 

While  the  tumor  grows 
with  great  rapidity,  the 
general  health  is  not  at  first 
affected,  the  urine  is  nearly 
normal,  heinaturia  is  rare, 
and  there  are  no  marked 
symptoms  of  pain.  It  is 
only  later,  when  the  size  of 
the  tumor  attracts  the  pa- 
rents' attention,  that  sur- 
Fio.  197.— SARCOMA  OF  THE  KIDNEY.  (Spitzy.)  gical  intervention  is  SOUght. 


ENURESIS— INCONTINENCE    OF    URINE  529 

These  tumors  grow  to  such  an  extent  that  they  fill  the  entire 
abdomen  (Fig.  197).  It  is  then  that  symptoms  of  compression  ap- 
pear : — ascites,  edema  of  the  lower  extremities,  suppression  of  urine, 
and  pressure  on  the  intercostal,  lumbar,  and  sacral  nerves.  Emacia- 
tion is  rapid  and  death  occurs  in  a  few  months. 

Diagnosis. — Rarely  is  there  an  opportunity  to  make  a  diagnosis 
before  the  appearance  of  a  large  tumor,  and  "of  all  the  large 
abdominal  tumors  in  infancy,  a  renal  tumor  is  the  most  frequent." 

Prognosis. — The  prognosis  is  extremely  grave.  Even  after 
surgical  intervention  recurrence  is  the  rule  if  the  patient  survives 
the  operation. 

Treatment  can  consist  only  of  nephrectomy.  The  size  of  the 
tumor  compels  removal  by  the  abdominal  route.  In  the  presence  of 
cachexia  operation  is  contraindicated. 


CHAPTER  LXIV 

BLADDER    DISEASES 

ENURESIS— INCONTINENCE    OF    URINE 

The  incontinence  of  urine  peculiar  to  children  is  the  nocturnal 
incontinence  which  is  manifest  by  involuntary  and  unconscious 
micturition  which  occurs  during  the  hours  of  sleep  and  is  not  ac- 
companied by  any  lesion  of  the  urinary  apparatus  which  rationally 
explains  the  infirmity  (Bazy).  It  is  an  affection  often  rebellious, 
and  in  certain  cases  resists  the  most  varied  treatment.  It  is  noted 
most  frequently  in  boys,  especially  in  children  of  a  neuropathic 
diathesis — many  are  epileptics. 

Symptoms. — The  incontinence  either  occurs  every  night  or  at 
certain  irregular  periods.  In  nearly  every  case  there  is  frequent 
urination  during  the  day.  The  incontinence  is  favored  by  heavy 
sleep,  unusual  fatigue,  and  the  ingestion  of  large  quantities  of 
fluid. 


530  BLADDER  DISEASES 

Frequently  incontinence  disappears  at  the  time  of  adolescence 
after  a  grave  disease  or  after  a  violent  emotion  (Broca). 

Diagnosis. — In  diagnosing  true  nocturnal  incontinence  it  must 
not  be  confused  with  symptomatic  incontinence  which  occurs  so  fre- 
quently as  the  result  of  phimosis,  preputial  adhesions,  anal  fissures, 
polypus  of  the  rectum,  stone  of  the  bladder,  etc.  All  these  varieties 
of  incontinence  must  be  eliminated  before  a  diagnosis  of  true 
nocturnal  incontinence  is  established. 

Treatment. — Reprimand  and  punishment  are  not  only  useless  but 
harmful,  since  they  only  increase  the  nervousness  which  we  seek  to 
allay.  Begin  treatment  by  establishing  proper  hygienic  measures. 
Diminish  the  quantity  of  fluids,  especially  at  night,  avoid  coffee, 
tea,  and  spiced  foods.  Do  not  let  the  patient  become  -fatigued,  and 
encourage  him  to  live  out  of  doors. 

The  only  internal  medication  that  is  worth  trying  is  thyroid 
extract,  which  has  given  some  excellent  results. 

If  the  milder  measures  are  not  effective,  two  operative  pro- 
cedures are  suggested  which  have  given  remarkable  results : 

(1)  Epidural  injection  of  a  weak  solution  of  cocain  or  artificial 
serum  in  the  sacral  canal  as  suggested  by  Cathelin. 

(2)  Retrorectal  injection  of  artificial   serum   as   suggested   by 
Jaboulay.      Spitzy   reports   this   method   as   being  superior  to   the 
epidural  injections.     It  is  based  on  the  assumption  that  nocturnal 
incontinence    results    from    some    functional    trouble    of    the    sym- 
pathetic nervous  system  which  is  produced  in  the  hypogastric  plexus. 
By  injecting  a  certain  quantity  of  artificial  serum  in  the  retrorectal 
space,  an  energetic  action  is  thereby  exercised  on  the  sympathetic 
fibers  or  the  nerve  ganglia,  either  by  stretching  or  by  excitation 
(Spitzy). 

The  needle  is  inserted  vertically  at  the  point  of  the  coccyx;  the 
index  finger  in  the  rectum  prevents  penetration  and  perforation 
of  the  rectal  wall. 

About  six  to  eight  drams  of  serum  is  injected  at  one  seance. 
The  effect  is  usually  immediate.  If  necessary  the  injection  may 
be  repeated. 


VESICAL    CALCULI  531 

VESICAL   CALCULI 

Etiology. — Stone  of  the  bladder  is  by  no  means  rare  in  early 
life,  and  is  most  frequently  found  in  poorly  nourished  children  in 
whom  the  oxidation  of  tissues  is  imperfectly  accomplished.  Boys 
are  more  frequently  affected  than  girls,  and  the  greater  number  of 
cases  occur  between  the  second  and  seventh  years.  Spitzy  observes 
that  the  urine  of  the  new-born  contains  an  excess  of  uric  acid,  which 
frequently  gives  rise  to  a  renal  calculus.  This  renal  concretion  then 
descends  into  the  bladder.  In  other  words,  vesical  stone  in  chil- 
dren usually  has  its  origin  in  the  kidney. 

It  is  an  incontestable  fact  that  in  the  child  the  central  focus  of 
vesical  stone  is  always  of  uric  origin  and  is  not  due  to  vesical 
infection. 

The  composition  of  the  stone  may  vary,  but  the  important  clinical 
fact  is  that  the  calculi  of  children  are  for  the  most  part  oxalate  of 
lime  stones,  more  or  less  voluminous,  very  hard,  of  irregular  sur- 
face— the  typical  mulberry  calculus. 

Symptoms. — The  symptoms  in  children  are  more  obscure  than  in 
the  adult.  This  is  due  not  merely  to  the  child's  inability  to  intelli- 
gently interpret  its  sensations,  but  to  certain  misleading  reflex 
phenomena  and  a  real  difference  in  the  pathological  picture.  For 
a  long  time  the  symptoms  may  be  so  vague  that  stone  of  the  blad- 
der is  not  suspected.  Carefully  interrogate  the  parents  about  the 
onset  of  the  affection,  the  character  of  the  pain,  the  peculiarities 
of  micturition,  etc. 

Pain. — The  intensity  of  the  pain  is  very  variable.  It  may  be 
absent,  or  it  may  appear  in  the  form  of  crises,  in  the  course  of 
which  the  child  cries  out,  stamps  his  feet,  puts  his  hands  on  his 
genitals,  and  drags  at  the  penis  and  the  prepuce.  Rectal  prolapse 
often  results  from  the  continued  straining.  Sometimes  there  is 
violent  abdominal  pain  with  vomiting,  which  simulates  an  intestinal 
disorder. 

Later  the  pain  is  localized  in  the  bladder,  the  perineum,  and 
the  penis,  and  we  note  that  it  is  associated  with  disorders  of  micturi- 
tion (dysuria). 


532  BLADDER  DISEASES 

Disorders  of  Micturition. — There  is  a  frequent  desire  to  urinate, 
due  to  special  irritability  of  the  bladder,  which  in  time  may  become 
a  veritable  incontinence. 

'Where  there  is  a  history  of  incontinence,  especially  an  inconti- 
nence which  occurs  not  only  during  the  night,  but  likewise  during 
the  day,  suspect  stone  of  the  bladder. 

Micturition  is  painful  at  the  beginning,  contrary  to  cystitis, 
where  the  pain  is  terminal. 

Another  characteristic  symptom  is  sudden  interruption  of  the 
stream  of  urine,  due  to  the  displacement  of  the  stone  by  the  con- 
tracting bladder  and  sudden  plugging  of  the  neck,  which  is  facili- 
tated by  the  absence  of  the  prostate  at  this  time  of  life. 

Again,  if  the  stone  is  small  and  elongated,  it  may  become  en- 
gaged in  the  urethral  orifice  and  be  the  cause  of  retention  of  the 
urine. 

Hematuria,  so  frequent  in  the  adult,  is  extremely  rare  in  chil- 
dren. 

Cystitis  may  appear  after  a  time,  accompanied  by  pain,  fre- 
quent micturition,  and  purulent  urine.  Since  other  causes  of  cystitis 
in  children  are  very  exceptional  the  presence  of  cystitis  is  strong 
evidence  in  favor  of  stone  of  the  bladder. 

EXAMINATION. — When  suspicion  is  directed  toward  stone  of  the 
bladder  by  any  of  the  above  symptoms,  a  local  examination  is  next 
in  order;  externally,  by  means  of  the  rectal  touch;  internally  by 
exploration  with  the  sound. 

As  a  rule  light  ether  anesthesia  should  be  employed.  A  rectal 
examination  is  specially  valuable  in  this  condition,  since  the  rudi- 
mentary prostate  and  seminal  vesicles  permit  us  to  easily  reach  the 
base  of  the  bladder,  and  when  combined  with  abdominal  palpation 
a  hard  body  like  a  stone  is  easily  felt;  and  when  the  stone  is  large' 
enough  it  may  even  be  grasped  between  the  rectal  and  abdominal 
fingers. 

In  exploration  of  the  bladder  by  means  of  the  sound  it  is  essen- 
tial that  asepsis  be  observed,  that  the  bladder  be  moderately  dis- 
tended with  sterile  water,  and  that  the  sound  be  passed  with  all 
gentleness.  Once  in  the  bladder  the  cavity  should  be  thoroughly 


VESICAL    CALCULI  533 

explored  at  all  points.  The  thoroughness  of  the  search  may  be 
aided  by  introducing  the  finger  in  the  rectum  at  the  same  time. 

If  convenient  the  radiograph  may  be  used,  and  if  the  result  is 
positive  intravesical  exploration  with  an  instrument  is  thus  avoided. 

Diagnosis. — There  need  be  no  mistake  made  if  direct  rectal  ex- 
amination and  exploration  of  the  bladder  be  employed.  Errors  arise 
because  of  the  insidious  onset  of  vesical  calculus.  Incontinence  of 
urine,  when  not  exclusively  nocturnal,  should  always  suggest  the 
possibility  of  stone  of  the  bladder.  The  bladder  symptoms  must 
not  be  attributed  to  phimosis  and  balanitis  without  confirmatory 
evidence. 

Treatment. — Surgical  intervention  is  the  only  means  of  remov- 
ing the  cause  of  the  trouble. 

Suprapubic  cystotomy  is  the  operation  of  choice.  This  opera- 
tion is  easily  performed,  since  in  children  the  bladder  is  more  of 
an  abdominal  than  pelvic  organ,  and  an  entrance  is  easily  effected 
just  above  the  pubes  without  opening  the  peritoneum. 

The  field  of  operation  is  disinfected  by  tincture  of  iodin  (half 
strength).  The  bladder  may  be  inflated  with  air  to  increase  the 
anterior  surface  of  the  bladder  uncovered  by  peritoneum. 

A  longitudinal  incision  is  made  just  above  the  symphysis;  the 
recti  are  separated  and  the  wound  retracted;  the  prevesical  fat  is 
dissected  away  with  the  finger;  the  distended  bladder  is  recognized 
and  seized  with  two  Kocher  clamps  placed  as  near  the  top  as  pos- 
sible and  on  each  side  of  the  median  line,  and  the  bladder  is  opened 
between  the  clamps  in  the  median  line.  After  separating  the  blad- 
der opening  the  stone  is  removed  by  means  of  a  tenaculum.  If 
there  is  no  serious  infection  or  intravesical  hemorrhage  the  bladder 
should  be  closed  by  two  rows  of  superimposed  sutures  of  cat-gut. 
(It  is  important  to  use  cat-gut;  if  silk  falls  into  the  bladder  it  may 
form  the  nucleus  of  a  new  stone.) 

The  first  line  of  sutures  includes  all  the  thickness  of  the  blad- 
der wall  except  the  mucosa.  The  second  line  enfolds  the  edges  by 
interrupted  Lembert  sutures.  The  greatest  attention  should  be  paid 
to  the  closure  of  the  bladder  wound  at  its  lower  part,  as  leakage 
generally  occurs  at  this  point. 


534  BLADDER  DISEASES 

When  the  suture  line  is  complete  its  effectiveness  may  be  proved 
by  injecting  water.  Suture  the  recti  muscles,  place  a  drain  in  the 
lower  angle  of  the  wound,  close  the  skin  incision,  and  leave  a  self- 
retaining  catheter  in  the  bladder. 

Watch  carefully  the  bladder  drainage  and  prevent  the  catheter 
from  being  blocked  with  incrustations  by  injecting  every  day  a 
small  quantity  of  boric  acid  solution. 

Remove  the  prevesical  drain  on  the  second  day  and  the  catheter 
on  the  fourth  day. 

This  operation  is  simple,  benign,  and  efficacious,  and  the  results 
are  excellent. 


TUMORS    OF    THE    BLADDER 

Tumors  of  the  bladder  are  rare  in  children  and  are  of  the  con- 
nective tissue  types — such  as  sarcoma,  fibrosarcoma,  myosarcoma, 
lymphosarcoma,  fibromyoma,  etc.  These  tumors  appear  in  the 
form  of  polypi  usually  attached  by  pedicles  to  the  base  of  the 
bladder. 

Symptoms. — The  first  symptoms  noticed  are  disorders  of  micturi- 
tion— dysuria,  incontinence  of  urine,  pains  in  the  belly,  which  sug- 
gest the  presence  of  calculus;  but  rectal  and  bladder  exploration 
eliminates  all  doubt.  Cystitis  accompanied  by  hematuria  is  always 
suggestive  of  either  bladder  tumor  or  bladder  tuberculosis.  The 
hematuria  of  neoplasm,  however,  is  abundant,  spontaneous,  and  re- 
bellious to  ordinary  therapeutic  measures. 

Tumors  of  the  bladder  develop  rapidly.  Their  local  extension 
is  a  grave  obstacle  to  the  excretion  of  urine,  hence  hydronephrosis  and 
pyelonephritis  are  possible  complications,  and  death  is  frequently 
caused  by  uremia.  These  tumors  extend  and  invade  the  neighbor- 
ing regions — uterus,  vagina,  prostate,  and  abdominal  wall. 

Treatment. — The  outlook  for  tumors  of  the  bladder  in  children 
is  extremely  grave.  Death  is  the  usual  termination.  In  certain 
rare  cases,  where  the  tumor  is  benign,  extirpation  may  be  attempted. 
In  the  majority  of  cases  the  treatment  is  symptomatic. 


PHIMOSIS  535 

CHAPTER  LXV 

PHIMOSIS    AND    PARAPHIMOSIS 

PHIMOSIS 

Phimosis  is  a  very  frequent  anomaly  and  refers  to  an  abnormal 
narrowing  of  the  preputial  orifice,  which  prevents  the  prepuce  from 
being  drawn  back  over  the  glans.  In  certain  very  accentuated 
cases  it  may  be  an  obstacle  to  urination.  The  degree  of  phimosis 
varies  considerably,  but  rarely  is  there  complete  preputial  occlusion. 
In  connection  with  this  malformation  the  length  of  the  prepuce  is 
a  matter  of  real  importance.  In  the  long  prepuce  with  a  narrow 
opening  the  pressure  of  the  urine  dilates  the  preputial  sac  and  stag- 
nates, causing  the  deposition  of  phosphatic  salts,  which,  with  the 
smegma,  is  a  source  of  constant  irritation. 

Phimosis  is  very  frequently  accompanied  by  adhesions  between 
the  glans  and  the  inner  surface  of  the  prepuce,  which  are  easily 
broken  down.  The  products  of  retained  secretion  are  also  to  be 
noted  in  the  accumulation  of  little  white  cheesy  masses  (smegma) 
which  collect  around  the  corona  of  the  glans.  Phimosis  is  usually 
associated  with  a  short  frenum. 

Clinical  Course. — It  is  quite  evident  if  the  preputial  orifice  be 
abnormally  small  considerable  effort  is  necessary  to  expel  the  urine, 
and  that  the  violent  straining,  which  causes  increased  abdominal 
pressure,  will  predispose  the  sufferer  to  such  secondary  dis- 
orders as  hernia  and  prolapsus  of  the  rectum.  Besides,  the  stag- 
nation of  urine  within  the  preputial  sac  predisposes  the  sufferer  to 
the  formation  of  preputial  calculi,  analogous  to  those  formed  in  the 
bladder. 

Again,  the  narrow  preputial  orifice  affords  no  adequate  outlet  to 
the  normal  secretion  and  prevents  a  proper  cleansing  of  the  glans ; 
hence,  smegma  collects  within  the  cavity,  infection  follows,  and 
inflammation  results,  giving  rise  to  balanitis.  Not  only  this,  but 
many  reflex  nervous  phenomena,  convulsions,  nocturnal  incontinence, 


536  PHIMOSIS  AND  PARAPHIMOSIS 

retention   of   urine,   masturbation,    incomplete   development   of   the 
glans,  and  liability  to  venereal  infection  may  be  charged  to  phimoeis. 
Treatment. — The  presence  of  phimosis  is  an  indication  for  opera- 
tion. 

BLOODLESS  STKETCHINQ  of  the  orifice  by  the  introduction  of  a 
pair  of  forceps  between  the  glans  and  the  prepuce  and  gradually 
opening  their  blades  is  very  painful  to  the  patient  and  necessitates 
subsequent  operation.  It  should  not  be  practised. 

In  very  young  children,  where  relief  is  needed  and  an  anesthetic 
is  to  be  avoided,  the  authors  simply  make  a  dorsal  slit  of  the  prepuce 
(with  or  without  grooved  director)  from  apex  to  corona  with  a  single 
cut  of  the  scissors.  This  is  quickly  done  and  causes  only  momentary 
pain.  The  adhesions  are  broken  up,  the  glans  cleansed,  and  the 
wound  without  suture  is  dressed  with  sterile  zinc  oxid  ointment. 
This  is  a  rapid  and  satisfactory  procedure  when  anesthesia  is  not 
to  be  employed.  In  cases  where  anesthesia  is  permissible  circum- 
cision is  the  procedure  of  choice. 

CIBCUMCISIOX. — This  small  operation  is  easily  performed,  frees 
the  patient  at  once  from  his  suffering,  and  disposes  for  all  time  of 
preputial  irritation. 

While  this  operation  is  comparatively  simple,  yet  results  far 
from  esthetic  are  often  seen.  The  tendency  is  to  re  more  too  much 
skin,  the  operator  forgetting  that  while  the  skin  of  the  prepuce  can 
be  freely  drawn  forward,  owing  to  its  great  mobility,  the  mucous 
membrane  is  definitely  held  in  position  by  its  attachment  to  the 
corona;  hence  the  skin  is  frequently  excised  at  a  much  higher  level 
than  the  niucosa. 

Again,  the  use  of  phimosis  forceps  is  unnecessary  and  misli ad- 
ing  and  should  be  abandoned. 

Operative  Procedure. — All  the  disinfection  that  is  practical  ran 
be  accomplished  by  thorough  cleansing  with  soap  and  water. 

The  instruments  required  are  four  hemostatic  forceps,  a  thumb- 
forceps,  a  straight  scissors  and  a  scissors  curved  on  the  flat,  two 
small  curved  needles  threaded  with  fine  catgut,  a  needle-holder  and 
four  fine  catgut  ligatures,  some  aseptic  gauze  and  sterile  zinc  oxid 
ointment. 


PHIMOSIS 


537 


The  child  is  given  light  ether  anesthesia.     On  each  side  of  the 
preputial  orifice  apply  a  hemostatic  forceps  and,  with  the  prepuce 


10S.  Tin;  I'IIKIM CK  IH 
HELD  TAUT  AND  A  SLIT 
u  MADE  ALONG  THE 

DOHHUM    OF    THE     PRE- 
PUCE WITH  SCIHSOHH. 


FIG.  199. — THE  EXCESS  PREPUCE  is  REMOVED 
WITH  CUHVEU  SCISSORS  LEAVING  A  SMALL 
COLLAR  OF  SKIN  AND  MUCOHA  AT  BAHE  OF 
CORONA. 


held  taut,  make  a  slit,  alonir  (he  dot-sum  of  I  lie  prepuce  willi  scissors 
(Fig.  198).  Gently  break  up  the  adhesions,  freeing  the  prepuce 
down  to  the  corona,  and 
d'-aiise  the  glans  of  all 
secretion.  With  the 
curved  scissors  remove  the 
-i  prepuce,  leaving  a 
small  collar  of  skin  and 

iiinco.-a.  at  the  base  of  the 
ci.rona  (  \'"iii.  !!>!)).  Li^ate. 

all  bleeding  points  and  be 
sure  that  hemostasis  is 
perfect  before  proceeding 
further.  Large  hemato- 

mata     inay     form     in     the 

loose      cellular      tissue      be-       l''I(J-  200.- -Tun   SKIN  AND  MI;C«JHA   AUK  SI-K  iti,i> 

AND  THE  ENDB  OF  CAT-GUT  LEFT  LONG  TO  HOLD 
neath    the    skin    if    hemo-  THE  GAUZE-STRIP  DRESSING  IN  PLACE. 


538 


PHIMOS1S  AND  PARAPHIMOSIS 


stasis  is  not  exact.  Suture  the  skin  and  mucosa  at  four  or  five  equi- 
distant points,  tying  and  leaving  the  ends  of  the  catgut  long,  for  use 
in  holding  the  dressing  in  position.  (Fig.  200.)  Fold  a  piece 
of  sterile  gauze  several  thicknesses  and  three- 
eighths  o^  an  inch  wide.  Tie  this  strip  of  gauze 
in  position  next  to  the  wound  margin  by  util- 
izing the  long  ends  of  the  catgut  sutures  (Fig. 
201),  and  smear  the  dressing  freely  with  sterile 
zinc  oxid  ointment.  This  ambulatory  dressing 
tied  in  with  the  sutures  affords  sufficient  protec- 
tion, and  at  the  end  of  a  week,  when  healing 
is  complete,  falls  off  with  the  absorption  of  the 
catgut. 

The  dressing  should  be  kept  well  smeared 

Fio.   201.  — GATJZB     with  zinc  oxid  ointment  or  carbolized  vaselin  to 
DRESSING  TIED  IN  ... 

PLACE.  prevent  the  urine  soaking  into  the  dressings. 


PARAPHIMOSIS 

Paraphimosis  is  a  sequela  of  phimosis.  The  child  out  of  simple 
curiosity  or  during  masturbation  slips  the  exuberant  foreskin  back 
of  the  glans  into  the  coronal  groove,  and  the  retracted  prepuce  thus 
forms  a  constricting  ring  at  the  base  of  the  glans. 

The  prepuce  becomes  edematous,  swells  to  enormous  propor- 
tions, and  finally  necroses.  In  extreme  cases  a  constriction  that  is 
allowed  to  go  unrelieved  may  cause  gangrene,  but  usually  ulceration 
of  the  constricting  ring  results  in  spontaneous  cure. 

Treatment. — In  most  cases  reduction  is  accomplished  by  holding 
the  glans  between  the  middle  and  index  fingers  and  pushing  in  the 
glans  with  the  thumb.  It  is  better  to  use  light  anesthesia. 
If  efforts  at  reduction  fail,  or  if  gangrene  threatens,  taxis  should  be 
abandoned  and  the  constricting  ring  of  prepuce  should  be  incised 
on  a  grooved  director  and  then  do  whatever  plastic  operation  the 
condition  requires. 


HYDEOCELE  539 

CHAPTER  LXVI 

DISEASES    OF    THE    TESTIS 

HYDROCELE 

Hydrocele  ordinarily  refers  to  an  accumulation  of  serous  fluid 
in  the  tunica  vaginalis.  It  is  frequently  found  in  the  new-born  and 
during  the  first  months  of  life. 

Normal  and  Pathological  Anatomy. — To  appreciate  the  varieties 
of  hydrocele  and  rationally  account  for  the  same,  it  is  only  neces- 
sary to  recall  the  fact  that  the  testicle  in  its  descent  from  the 
abdomen  into  the  scrotum  is  preceded  by  a  pouch  of  peritoneum — 
the  processus  vaginalis.  At  birth  the  portion  of  the  pouch  extend- 
ing from  the  internal  ring  to  the  upper  part  of  the  testicle  is 
normally  closed  and  obliterated,  the  lower  portion  of  the  pouch  re- 
mains as  the  tunica  vaginalis  testis. 

Suppose  that  normal  obliteration  of  this  process  is  defective, 
then  it  is  obvious  that  the  hydrocele  may  occupy  the  whole  or  any 
part  of  the  peritoneal  pouch  (processus  vaginalis).  Hence  the 
variety  of  hydrocele  depends  upon  the  variety  of  defect  in  the 
obliteration  of  the  peritoneal  pouch. 

Varieties. — In  congenital  hydrocele  the  whole  peritoneal  pouch 
remains  open  and  is  filled  with  serous  fluid.  It  may  communicate 
with  the  peritoneal  cavity  by  a  very  narrow  opening,  in  which  case 
it  is  characterized  by  being  reducible  under  pressure.  Furthermore, 
there  is  a  noticeable  variation  in  size.  It  fills  up  during  the  day 
and  empties  during  the  night,  or  may  disappear  for  a  time,  a  fact 
often  noted  by  the  parents.  In  a  badly  nourished  child  a  communi- 
cating hydrocele  may  be  symptomatic  of  tuberculous  peritonitis. 

In  infantile  hydrocele  the  upper  part  of  the  peritoneal  pouch  is 
closed,  the  lower  portion  communicates  with  the  tunica,  and  when 
distended  with  fluid  is  liable  to  be  mistaken  for  an  inguinal  hernia. 

In  encysted  hydrocele  of  the  cord  the  peritoneal  pouch  is  closed 
above  and  below,  the  intervening  portion  being  distended  with  fluid. 


540  DISEASES  OF  THE  TESTIS 

Infantile  hydrocele  is  frequently  found  in  the  new-born  and  is  often 
accompanied  by  edema  of  the  scrotum.     It  lasts  but  a  few  days 
and  is  probably  due  to  some  injury  received  by  the  scrotum  at  birth. 
Symptoms  will  depend  upon  the  variety  of  hydrocele. 

In  congenital  hydrocele  there  is  a  smooth,  tense,  elastic,  ovoid 
tumor  of  the  scrotum;  flat  on  percussion,  and  usually  reducible 
under  gentle  pressure.  The  volume  of  the  tumor  varies,  gradually 
emptying  during  the  night  when  the  child  is  recumbent  and  refill- 
ing during  the  day  when  the  child  is  about.  There  is  more  or  loss 
impulse  on  crying  or  straining.  The  tumor  is  translucent  when  a 
light  (candle  or  electric  bulb)  is  placed  behind  it,  and  the  examiner 
looks  through  a  cylinder  of  rnetal,  rubber,  or  partially  closed  hand 
pressed  against  the  opposite  side. 

In  infantile  hydrocele  the  symptoms  are  similar  to  those  of  con- 
genital hydrocele,  but  the  tumor  is  not  reducible. 

In  encysted  hydrocele  of  the  cord  there  is  felt  one  or  more  small, 
rounded  cystic  tumors,  about  the  size  of  an  almond,  connected  with 
the  cord,  and  distinct  from  the  testicle.  They  are  very  mobile  in 
all  directions  and  may  be  forced  en  masse  into  the  inguinal  canal 
and  thus  mislead  by  an  apparent  reduction. 

Diagnosis. — The  practical  point  in  hydrocele  is  the  fact  that  it 
simulates  hernia,  from  which  it  is  to  be  differentiated.  It  is  not 
infrequent  to  find  a  truss  applied  to  a  hydrocele  of  the  cord,  mis- 
taken for  a  hernia. 

The  character  of  the  tumor  depends  upon  its  contents.  Is  it  a 
loop  of  gut  or  free  fluid  ?  Get  a  careful  history  from  the  parents ; 
if  the  swelling  extends  over  a  long  period  without  general  disturb- 
ance it  points  to  hydrocele.  Note  if  reduction  is  difficult.  If  the 
volume  of  the  tumor  is  larger  during  the  night  than  during  the  day, 
it  points  to  congenital  hydrocele. 

The  reduction  of  a  hernia  by  taxis  is  sudden  and  accompanied 
by  gurgling,  in  a  congenital  hydrocele  it  is  slow  and  silent.  A 
hernial  tumor  reappears  suddenly  on  coughing  or  straining,  a  hydro- 
cele reappears  slowly. 

Intestine  is  resonant  on  percussion,  hydrocele  is  flat. 

A  hydrocele  is  translucent ;  but  it  must  be  remembered  that  the 


HYDROCELE 


541 


light  test  in  infants  is  not  reliable  as  a  differential,  since  hernia  in 
a  child  may  also  be  translucent. 

Treatment. — It  must  be  remembered  that  congenital  hydrocele 
has  a  tendency  to  spontaneous  cure  during  the  first  months  of  life 
by  physiological  obliteration  of  the  sac.  The  expectant  treatment  is 
worth  trying  in  all  hydroceles  of  childhood.  If  the  hydrocele  persists 
or  increases,  in  size  a  radical  cure  is  indicated. 

In  the  RATIONAL  TREATMENT  of  hydrocele  it  must  be  evident, 
first,  that  no  external  application  of  any  medicament  can  be  of 
therapeutic  value ;  second,  the  possible  communication  of  the  sac 
with  the  peritoneal  cavity  em- 
phasizes the  dangers  of  inject- 
ing such  substances  as  carbolic 
acid  and  iodin  to  obliterate  the 
sac.  Such  procedures  are  un- 
safe and  cause  unnecessary  com- 
plications (sloughing  of  scro- 
tum, suppurative  orchitis,  etc.). 
A  certain  number  of  cases  will 
be  cured  by  simple  aseptic  as- 
piration. 

Operation. — The  skin  is 
prepared  by  painting  with  tinc- 
ture of  iodin  (half  strength). 
The  sac  is  made  tense  and  the  aspirating  needle  inserted  so  as  to 
avoid  the  testicle,  which  lies  at  the  lower  posterior  portion  of  the 
scrotum.  The  puncture  should  be  made  in  front  and  above,  the 
needle  pointing  upward  and  backward.  (Fig.  202.)  After  with- 
drawal of  the  fluid  the  puncture  is  closed  with  collodion-aristol. 

If  after  several  tappings  there  is  recurrence,  a  radical  cure  is 
indicated. 

RADICAL  CURE  is  the  least  dangerous  and  the  most  efficient 
remedy.  The  procedure  is  practically  the  same  as  for  the  radical 
cure  of  hernia,  viz. :  isolation  and  excision  of  the  sac. 

HYDROCELE  COMPLICATED  BY  HERNIA  should  be  treated  by  aspi- 
ration and  truss.  If  not  cured  after  two  years  do  a  radical  cure. 


FIG.  202. — TAPPFNG  A  HYDKOCELE.  (Keen's 
Surgery.) 


542 


DISEASES  OF  THE  TESTIS 


HYDKOCELE  OF  THE  CANAL  OF  NUCK  in  girls  is  treated  on  the 
same  principles  as  stated  above. 


UNDESCENDED    AND    MISPLACED    TESTICLE 

It  will  be  recalled  that  in  normal  development  the  testicles 
migrate  during  fetal  life  from  the  abdomen,  through  the  inguinal 
canal,  to  their  permanent  position  in  the  scrotum.  It  is  evident 
that  in  faulty  development  either  the  testicle  may  permanently 
lodge  at  any  point  between  its  original  site  and  the  scrotum — un- 
descended  testicle- — or  it  may  descend,  but  finally  lodge  in  some 

abnormal   position — mis- 
placed testicle. 

Undescended  Testicle 
(Cry  pt  or  chid  is  w.) — 
Here  the  testicle  in  its 
migration  has  failed  to 
reach  the  scrotum  and 
may  be  retained  (a)  in 
the  abdomen;  (b)  in  the 
inguinal  canal  (most  fre- 
quent) ;  (c)  just  exter- 
nal to  the  external  ring. 
This  malformation  may 
be  either  unilateral  or  bi- 
lateral. (Fig.  203.) 
Misplaced  testicle  (ectopia  testis)  may  take  a  position  (a)  in 
front  of  the  thigh  near  the  saphenous  opening;  (b)  in  the  perineum 
in  front  of  the  anus.  These  abnormal  positions  of  the  testicle  have 
not  only  an  important  physical  and  psychical  influence  on  the  growth 
of  the  individual,  but  they  are  associated  with  grave  pathological 
possibilities. 

It  must  be  remembered  that  the  testicle  is  not  only  a  gland  with 
a  procreative  function,  but  it  is  a  gland  with  an  internal  secretion 
essential  to  the  development  of  the  distinctly  masculine  type. 


FIG.     203. — BILATERAL-INGUINAL     UNDESCENDED 
TESTICLE. 


UXDESCEKDED    AXD    MISPLACED    TESTICLE        543 

Unilateral  ectopia  may  be  compensated  by  an  increase  of  the 
other  testicle  and  a  vigorous  masculine  type  be  developed,  but 
in  bilateral  ectopia  degeneration  is  manifest  in  rudimentary  organs 
and  a  reversion  to  the  feminine  type.  Hence  these  sufferers  should 
receive  the  most  careful  consideration  since  their  fate  largely  de- 
pends upon  their  management  before  puberty. 

Complications. — (a)  An  undescended  testicle  is  usuany  an  im- 
perfectly developed  organ,  and  if  not  corrected  before  puberty  its 
ability  to  secrete  spermatozoids  is  probably  lost;  hence,  in  bilateral 
displacement,  the  individual  is  probably  sterile. 

(b)  These  children  have  an  open  vaginal  process,  which  sub- 
jects them  to  the  danger  of  a  present  or  potential  hernia. 

(c)  These  misplaced  testicles  are  predisposed  to  torsion  of  the 
cord  from  the  action  of  the  inguinal  muscles,  which  gives  rise  to 
severe  disturbances,  such  as  pain,  nausea,  and  vomiting,  frequently 
simulating  appendicitis  or  strangulated  hernia. 

(d)  Imperfect  development,  constant  irritation,  and  pressure  of 
surrounding   structures   predispose   the   retained    testicle   to   malig- 
nant disease  (sarcomatous  degeneration). 

(e)  The  deformity  itself  is  important  enough  to  warrant  every 
possible  means  being  used  for  its  correction. 

Prognosis. — Remember  that  the  majority  of  undescended  testicles 
are  cases  of  delayed  descent,  and  a  large  number  will  make  their 
way  to  the  scrotum  before  the  age  of  puberty;  hence  early  inter- 
ference is  contraindicated  except  for  complications ;  and  castration 
in  a  child  is  under  all  circumstances  to  be  avoided. 

Symptoms. — Do  not  mistake  retracted  testicle  for  undescended 
testicle.  It  will  be  recalled  that  in  childhood  the  inguinal  canal  is 
patent  and  the  cremasteric  reflex  strong;  it  is  not  unusual  for  one 
or  both  testicles  to  be  drawn  up  temporarily  by  the  cremaster  muscle 
into  the  inguinal  canal  and  thus  simulate  undescended  testicle.  It 
has  happened  that  a  surgeon  prepared  to  operate  for  undescended 
testicle  finds,  after  anesthesia  is  established,  both  testicles  in  the 
scrotum. 

Retracted  testicle  is  temporary,  retained  testicle  is  permanent. 
Hence  absence  of  testicle  in  the  scrotum  is  to  be  considered  sympto- 


544  DISEASES  OF  THE  TESTIS 

matic  of  undescended  testicle  only  with  the  above  reservation.  An 
unusually  small  and  undeveloped  scrotum  is  found  in  all  these  chil- 
dren, the  result,  not  the  cause,  of  the  condition. 

Careful  examination  of  the  inguinal  canal  and  its  surroundings 
will  usually  disclose  the  position  of  the  testicle  (unless  within  the 
abdomen),  and  the  discovery  of  a  small  tumor  in  the  canal,  pain- 
ful on  pressure,  taken  in  connection  with  the  empty  scrotum,  may 
be  regarded  as  a  reliable  symptom  of  non-descent. 

Failing  to  find  the  testicle  in  the  inguinal  region,  the  region 
over  the  saphenous  opening  and  the  perineum  should  be  searched 
for  misplaced  testicle. 

Treatment. — Remember  that  a  large  number  of  undescended 
testicles  will  make  their  way  into  the  scrotum  before  the  age  of 
puberty. 

Hence  uncomplicated  undescended  testicle  needs  no  treatment 
before  the  tenth  year.  Operation  should  be  done  between  the  tenth 
and  twelfth  year.  In  very  early  childhood  massage  may  help  to 
bring  the  testicle  down,  but  after  this  period  it  is  a  useless  pro- 
cedure. 

COMPLICATIONS. — In  nearly  all  cases  of  undescended  testicle 
situated  in  the  inguinal  canal  a  congenital  hernial  sac  is  present. 
Hence  hernia  and  undescended  testicle  are  usually  coincident. 

It  will  be  readily  appreciated  how  difficult  it  is  to  keep  the  hernia 
in  place  without  injuring  the  testicle;  not  only  this,  but  there  is 
always  danger  of  strangulation.  It  is  sometimes  possible  to  keep 
the  hernia  in  place  by  means  of  a  "forked  truss" — a  truss  with  a 
"forked"  pad  to  avoid  pressure  on  the  testicle.  However,  all  forms 
of  truss  cripple  the  child  and  cannot  be  worn  without  danger.  Hernia 
complicating  undescended  testicle  is  a  positive  indication  for  opera- 
tive interference. 

In  the  early  months  no  truss,  no  treatment,  is  necessary,  since 
the  dangers  of  strangulation  at  this  period  are  very  small.  But 
when  the  child  reaches  from  the  second  to  the  third  year  (depend- 
ing upon  its  nutritional  coefficient)  an  operation  for  the  radical 
cure  of  the  hernia  and  retained  testicle  should  be  performed. 

Hence,  the  following  rules  of  treatment  should  be  observed: 


UNDESCENDED    AND    MISPLACED    TESTICLE 


545 


(a)  Uncomplicated  undescended  testicle — operation  between  the 
tenth  and  twelfth  years. 

(b)  Undescended    testicle    complicated    with    hernia — operation 
between  the  second  and  third  years. 

(c)  Massage  in  very  early  childhood  is  permissible,  but  it  is 
difficult,  sometimes  dangerous,  and  seldom  successful. 

Operation. — The  operation  of  Bevan  has  been  so  perfected  that 
its  author  claims  that  testicles  which  lie  entirely  within  the  abdomen 
can  in  almost  all  cases  be  brought  down  and  retained  permanently  in 
the  scrotum. 


FIG.  204. — INCISION  THROUGH  SKIN,  SUPERFICIAL  FASCIA,  APONEUHOSIS  OF  THE 
EXTERNAL  OBLIQUE,  AND  THE  PERITONEAL  POUCH  OPENED.  (Bevan.) 

The  technique  of  the  operation,  as  given  by  its  author,  is  as 
follows  ("Keen's  Surgery,"  Vol.  IV,  p.  594)  : 

"An  incision  is  made  about  three  inches  long  over  the  inguinal 
canal.  This  cut  should  divide  skin,  superficial  fascia,  and  the 
aponeurosis  of  the  external  oblique. 

"Under  the  external  oblique  will  be  found  a  pouch  of  peritoneum 
extending  from  the  abdominal  peritoneum  through  the  canal  and 
down  to  the  scrotum.  Sometimes  the  pouch  extends  to  the  bottom 
of  the  scrotum,  even  in  cases  in  which  the  testicle  has  never  been 
out  of  the  abdominal  cavity.  This  pouch  of  peritoneum  is  covered 


546 


DISEASES  OF  THE  TESTIS 


by  the  cremasteric  muscle  and 
fascia,  and  the  transversalis 
fascia.  These  thin  layers 
should  be  divided  and  the  peri- 
toneal pouch  opened.  (Fig. 
204.)  The  vaginal  process  of 
peritoneum  should  be  divided 
transversely  well  above  the  tes- 
ticle. Care  should  be  taken  not 
to  injure  the  cord,  and  in  chil- 
_,  dren,  where  the  peritoneal  proc- 

FIG.  205. — UPPER  END  OF  VAGINAL  PROCESS 

LIGATED.    PDRSE-STRING  SUTURE  CLOS-    ess   IS    as    delicate   as   tissue   pa- 
ING  LOWER  END  OF  VAGINAL   PROCESS 

AND  FORMING  A  TUNICA  VAGINALIS  FOR    per,      the     dissection     must     be 
THE  TESTICLE.   (Bevan.)  .,,  i        -,T 

made  with  great  care  and  with 

small  instruments.    After  complete  transverse  division  of  the  vaginal 
process  the  upper  end  is  closed  with  a  catgut  ligature,  as  is  the  sac 
in  a  hernial  operation,  and  the  lower  end  is  closed  with  a  purse- 
string  suture,  making  a  tunica  vaginalis  for  the  testis.     (Fig.  205.) 
Then  with  a  gauze  sponge  the  peritoneum  is  carefully  wiped  off  from 
the  cord.     As  the  wiping  proceeds  the  cord  will  gradually  lengthen 
until   the   testicle   can  be 
brought    well   down   upon 
the  thigh.  // 

"Tense  fibrous  strands 
in  the  cord  are  to  be  torn 
either  with  the  fingers  or 
blunt  dissecting  forceps, 
and  the  cord  is  to  be  freed 
of  everything  except  the 
vas  and  th^  vessels.  (Fig. 
206.) 

"When,  as  in  the  excep- 
tional case,  a  large  peri- 
toneal pouch  extends  to 
the  bottom  of  the  scrotum, 

FIG.  206. — CORD  LENGTHENED,  TESTICLE  IREED 
the    testicle     can    now    be  AND  READY  FOR  REPLACEMENT.  (Bevan.) 


TUBEKCULOSIS    OF    THE    TESTICLE 


547 


pushed  into  this  and  retained  by  a  purse-string  suture  within  the 
neck  of  the  scrotum.  As  a  rule,  however,  it  is  necessary  to  make 
a  cavity  by  blunt  dissection  with  the  finger.  (Fig.  207.) 

"In  a  few  cases — but  these  will  be  quite  the  exception — it  is 
found,  even  after  the  free  exposure  of  the  cord,  that  it  is  not  long 
enough  to  permit  of  the  reduction  well  into  the  scrotum.  In  such 
cases  it  will  be  seen  that  the  shortened  structures  are  the  spermatic 
artery  and  veins.  These  can  be  divided  between  two  ligatures,  care 
being  taken  to  avoid  injury  to  the  vas  and  the  vessels  of  the  vas. 

"It  will  then  be  found  that 
the  testicle  can  by  gentle  trac- 
tion be  brought  down  sufficiently 
to  replace  it  in  the  scrotum 
without  tension. 

"The  wound  is  now  closed  as 
in  an  ordinary  hernia  operation, 
not  transplanting  the  cord  as  is 
done  in  the  Bussini  operation, 
but  allowing  it  to  remain  in  its 
normal  position.  The  success  of 
the  operation  depends  upon  free- 
ing the  testicle  so  completely 
that  it  can  be  placed  in  a  roomy 

FIG.   207. — MAKING   POCKET  IN  THE  SCRO- 

pocket    Well    down    in    the    SCro-  TUM  FOR  RECEPTION  OF  THE  TESTICLE. 

.  ,  „  (Bevan.) 

turn  without  tension. 


TUBERCULOSIS    OF    THE   TESTICLE 

Tuberculosis  of  the  testicle,  although  not  frequent  in  childhood, 
is  by  no  means  rare.  Statistics  show  that  it  is  a  disease  of  early 
childhood,  usually  before  the  age  of  seven  years.  It  is  an  interest- 
ing observation  that  undescended  testicle,  which  is  frequently  the 
site  of  malignant  growths,  is  rarely  affected  by  tuberculosis  (Broca). 

Clinical  Picture. — In  children  the  lesion  first  appears  in  the 
testicle  itself,  whereas  in  the  adult  the  epididymis  is  where  we  ex- 
pect to  find  it. 


548  DISEASES  OF  THE  TESTIS 

While  we  observe  the  same  general  characteristics  of  the  disease 
in  children  as  in  adults,  there  is  one  clinical  feature  which  merits 
special  attention — the  frequency  of  the  acute  form  of  tuberculous 
orchitis  in  very  young  children.  Without  any  previous  warning  of 
local  disease  the  testicle  suddenly  becomes  the  site  of  acute  inflam- 
matory reaction,  which  subsides  in  a  few  days,  leaving  only  some 
nodulated  areas;  or  it  may  go  on  to  the  formation  of  a  tuberculous 
abscess,  which  opens  and  leaves  in  its  wake  a  fistulous  tract. 

As  a  rule  the  process  is  subacute  or  chronic,  marked  by  swelling 
of  the  testicle,  which  feels  hard  and  nodular.  At  times  the  testicle 
and  epididymis  form  a  tumor  mass,  in  which  the  two  cannot  be 
distinguished.  The  involvement  of  the  cord  is  evidenced  by  thick- 
ening, induration,  and  nodular  areas  along  its  course.  The  blad- 
der, prostate,  and  seminal  vesicles  are  much  more  rarely  invaded 
in  children  than  in  adults.  The  clinic  form  may  follow  an  acute 
attack,  or  it  may  be  chronic  from  the  start. 

Diagnosis. — As  a  rule  the  diagnosis  is  not  difficult.  The  tume- 
faction, nodulation,  involvement  of  the  cord,  suppuration,  and 
fistulization  are  all  characteristic. 

In  the  chronic  form  it  will  be  necessary  to  differentiate  syphilitic 
testicle  and  malignant  disease.  Remember  that  syphilitic  testicle 
is  observed  very  early,  especially  in  the  new-born,  associated  with 
other  signs  of  hereditary  syphilis ;  that  its  progress  is  very  indolent, 
and  that  the  affection  is  usually  bilateral.  It  is  not  characterized 
by  suppuration  and  is  amenable  only  to  antisyphilitic  treatment. 

Malignant  disease  is  recognized  by  the  rapidity  of  the  growth 
and  the  size  it  attains. 

Treatment. — The  treatment  of  tuberculous  testicle  in  childhood 
should  be  hygienically  radical,  but  locally  conservative.  Unlimited 
fresh  air  and  sunshine,  with  substantial  alimentation.  Rest  in  bed 
if  the  process  is  acute,  and  suspension  of  the  testicle  in  all  cases. 
Here,  as  in  other  parts  of  the  body,  the  local  infection  is  often  con- 
quered by  raising  the  vital  resistance  of  the  body  tissues  through 
improved  hygienic  measures.  A  high  vital  index  is  more  efficacious 
than  the  knife. 

The  acute  abscess  requires  simple  incision.     The  chronic  abscess 


EPISPADIAS  549 

should  be  aspirated  and  injected  with  iodoform  and  glycerin  emul- 
sion.    Fistulous  tracts  require  curetting  and  cauterization. 
Castration  is  rarely  called  for. 


SARCOMA   OF    THE   TESTICLE 

The  testicle  is  a  frequent  site  of  malignant  growths  in  child- 
hood. It  is  possible  that  traumatism  plays  a  part  in  the  causation 
of  these  tumors  and  explains  the  relative  frequency  of  sarcomatous 
degeneration  in  undescended  testicle. 

The  starting  point  is  usually  in  the  testicle  itself,  but  soon  the 
epididymis  is  involved  and  the  process  rapidly  extends  along  the 
spermatic  cord  to  the  abdominal  cavity.  If  untreated,  the  scrotal 
tissues  become  involved  and  present  a  fungous  mass  of  ulcerating 
tissue. 

Deep  palpation  of  the  abdomen  will  reveal  enlarged  glands  in 
the  iliac  and  lumbar  region.  The  later  stages  exhibit  the  usual  evi- 
dences of  cachexia  and  malignant  toxemia. 

The  rapidity  of  the  growth  and  futility  of  specific  treatment 
distinguish  it  from  tuberculous  or  syphilitic  testicle. 

Treatment. — Removal  of  the  testicle  and  the  cord  as  high  up  as 
possible  as  soon  as  the  disease  is  recognized.  Results,  however,  are 
not  promising;  recurrence  is  the  rule. 

Bevan's  suggestion  to  supplement  castration  by  an  extended 
treatment  with  Coley's  mixed  toxins  is  worth  trying. 


CHAPTER  LXVII 

EPISPADIAS    AND    HYPOSPADIAS 

EPISPADIAS 

Pathology.— -Epispadias  is  a  congenital  malformation  character- 
ized by  an  abnormal  opening  of  the  urethra  on  the  dorsum  of  the 


550  EPISPADIAS  AND  HYPOSPADIAS 

penis.  It  is  a  rare  deformity  and  is  often  associated  with  congenital 
vesical  fissures.  The  developmental  explanation  of  this  defect  is 
somewhat  ambiguous.  According  to  Taylor,  the  erectile  bodies  have 
become  reversed,  so  that  the  corpus  spongiosum  occupies  the  dorsal 
position,  and  hence  urethral  defects  present  on  the  dorsal  surface. 
The  deformity  varies  according  as  the  defect  involves  the  entire 
length  of  the  penile  urethra  or  only  a  part.  We  distinguish  two 
varieties  of  epispadias  according  to  the  position  of  the  cleft :  peno- 
pubic  epispadias  and  balanic  epispadias.  In  penopubic  epispadias 
the  defect  involves  the  entire  length  of  the  urethra,  and  there  are 
often  associated  malformations,  such  as  exstrophy  of  the  bladder, 
hernia  of  the  bladder,  and  undescended  testicle. 

In  balanic  epispadias  (much  more  rare  than  the  complete)  the 
urethral  opening  is  on  the  dorsal  surface  at  the  base  of  the  glans, 
the  urethral  segment  of  the  glans  being  represented  by  a  dorsal 
groove. 

The  penis  is  atrophied  and  drawn  up  toward  the  pubis;  the 
prepuce  is  redundant  and  lies  like  an  apron  over  the  ventral  side  of 
the  glans,  so  that  it  is  necessary  to  draw  the  penis  down  by  seizing 
the  redundant  foreskin  of  the  inferior  surface,  to  perceive  the  median 
groove. 

Symptoms. — The  symptoms  vary  according  to  the  variety  of 
epispadias.  This  deformity  causes  grave  trouble  in  micturition, 
and  later  it  compromises  the  sexual  function.  In  partial  epispadias 
the  urine  can  be  retained,  but  the  abnormal  stream  of  urine  spreads 
out  laterally  and  soils  the  neighboring  parts.  In  complete  epispa- 
dias incontinence  of  urine  is  the  result. 

The  sexual  function  is  compromised  by  atrophy  of  the  penis, 
which  is  a  future  obstacle  to  coitus,  and  the  seminal  fluid  escapes 
in  a  dribble  and  cannot  be  projected  into  the  vaginal  canal.  It  is 
well  to  note  that  epispadias  in  the  female  is  very  rare,  and  the 
changes  in  the  conformation  of  the  external  genitals  will  hardly 
be  recognized  by  the  parents.  The  incontinence  which  accompanies 
the  deformity  in  the  female  is  the  only  symptom  which  suggests 
its  presence.  The  sexual  function  is  normal. 

Treatment. — In  cases  of  epispadias  with  incontinence  of  urine 


EPISPADIAS 


551 


no  local  plastic  operations  will  restore  the  bladder  sphincter;  it  is 
necessary,  whether  there  is  a  coexisting  exstrophy  of  the  bladder 
or  not,  to  treat  the  epispadias  in  the  same  manner — by  implanting 
the  ureters  into  the  bowel. 

In  the  milder  forms  of  epispadias  an  endeavor  is  made  to  create 
normal  conditions  by  changing  the  groove  into  a  tube  by  the  use 
of  plastic  flaps. 

It  is  obvious  that,  in  order  to  create  proper  conditions  for  heal- 
ing, the  urine  must  be  temporarily  diverted  from  the  newly  con- 
structed urethra.  Hence:  As  a  necessary  preliminary  step,  perineal 


FIG.  208. — DUPLAY'S  OPERATION  FOR  EPISPADIAS. 

A.  The  denuded  surfaces  on  each  side  the  corpora  cavernosaj     B.  The  denuded  surfaces 
brought  together  over  a  glass  rod,  and  fixed  with  quill  and  button  sutures. 

drainage  should  be  instituted  (external  urethrotomy)  and  main- 
tained until  healing  of  the  new  canal  is  complete. 

In  constructing  the  new  canal  the  operation  of  Duplay  is  by  far 
the  most  satisfactory. 

The  roof  of  the  urethra  is  formed  by  denuding  "a  rectangular 
strip  of  tissue  about  one-fourth  of  an  inch  in  width  from  each  side 
of  the  corpora  cavernosa,  and  three-fourths  of  an  inch  from  the 
middle  line  of  the  dorsum  of  the  penis,  extending  from  the  apex 
of  the  glans  penis  down  to  the  epispadiac  opening."  (Horwitz.) 
The  denuded  surfaces  are  brought  together  by  quill  and  button 
sutures,  over  a  glass  rod  or  catheter  (Fig.  208).  After  healing  is 


Or   OSTEQl^ 

PI   /i  10  ^     \       01  Mr  ,M: 


552  EPISPADIAS  AND  HYPOSPADIAS 

complete  it  will  be  necessary  to  form  a  junction  between  the  new 
urethra  and  the  epispadiac  opening  by  freshening  and  firmly  ap- 
proximating the  edges.  It  may  be  necessary  to  do  several  minor 
plastic  operations  before  the  closure  is  complete. 

HYPOSPADIAS 

Pathology. — Hypospadias  is  characterized  by  an  abnormal  open- 
ing of  the  urethra  on  the  under  surface  of  the  penis,  and  may  vary 
from  a  small  opening  to  a  complete  defect  of  the  penoscrotal  urethra. 
This  malformation  is  quite  frequent,  especially  the  variety  in  which 
the  abnormal  orifice  is  situated  on  the  under  surface  of  the  glans. 
Heredity  undoubtedly  plays  an  important  role  in  the  appearance 
of  this  defect,  since  there  are  certain  hypospadiac  families.  Broca 


FIG.  209. — HYPOSPADIAS  OF  THE  GLANS  (diagram). 

A.  The  urethral  opening  is  at  the  base  of  the  glans  with  a  groove  on  the  under  surface  of 
the  glans  extending  from  the  abnormal  orifice  to  the  normal  position  of  the  meatus; 
B.  Abnormal  orifice,  and  a  normal  meatus,  but  its  canal  ends  blindly. 

and  Mouchet  observe  that  it  is  a  frequent  malformation  among  the 
Bourbons. 

Clinical  Varieties. — There  are  three  varieties  of  hypospadias,  di- 
vided according  to  the  position  in  which  the  termination  of  the 
urethra  is  found. 

(1)  Hypospadias  of  the  Glans. — The  urethral  opening  is  at  the 
base  of  the  glans,  sometimes  so  small  that  it  can  scarcely  be  dis- 
covered. As  a  rule  there  is  a  more  or  less  pronounced  groove  on 
the  under  surface  of  the  glans,  extending  from  the  abnormal  orifice 
to  the  normal  position  of  the  meatus  (Fig.  209A)  ;  or  there  may  be 
an  abnormal  orifice  and  a  normal  meatus,  but  its  canal  ends  blindly 
(Fig.  209B). 

The  glans  is  small  and  curves  downward ;  the  frenum  is  absent ; 
the  prepuce  though  exuberant  covers  only  the  superior  and  lateral 

1.  rj  3  J  J 


HYPOSPADIAS 


553 


surfaces  of  the  glans,  and  is  wanting  on  the  inferior  aspect  of  the 
glans.  This  appearance  of  the  prepuce  alone  is  sufficient  to  permit 
a  diagnosis  of  hypospadias. 

(2)  Penile  and  Penoscrotal  Hypospadias. — In  penile  hypospa- 
dias  the  urethral  open- 
ing occupies  a  point 
somewhere  on  the  in- 
ferior surface  of  the 
penis.  (Fig.  210.)  In 
the  penoscrotal  variety 
the  urethral  orifice  is 
further  back,  at  the 
penoscrotal  angle. 
There  may  be  a  ure- 
thral canal  in  front  of 
the  abnormal  orifice 
(Fig.  21  IB),  or  simply 
a  more  or  less  devel- 
oped groove  (Fig. 
211  A)  ;  or  in  place  of 
the  groove  there  may  be  a  fibrous  band  extending  between  scrotum 
and  the  inferior  surface  of  the  penis  by  which  the  penis  is  held  curved 
downward. 


FIG.  210. — PENILE  HYPOSPADIAS.  (Broca.) 


FIG.  211. — PENOSCROTAL  HYPOSPADIAS  (diagram). 

A.  Penoscrotal  orifice  with  a  groove  in  front;  B.  Penoscrotal  orifice  with  a  blind  urethral 
canal  in  front  of  the  abnormal  orifice. 

(3)  Scrotal  or  Perineoscrotal  Hypospadias. — In  this  more  ex- 
tensive fissure  of  the  genital  organs  the  formation  approaches  the 
female  type.  The  scrotum  is  divided  into  two  independent  pockets, 


554  EPISPADIAS  AXV  HYPOSPADIAS 

the  urethral  orifice  opening  between  them  or  at  the  perineoscrotal 
angle.  The  testicles  are  generally  atrophied  and  ectopic.  It  is  evi- 
dent that  as  the  meatus  lies  between  two  cutaneous  folds  resembling 
the  vulva,  and  the  atrophied  penis  is  not  unlike  the  clitoris,  this 
variety  presents  an  appearance  which  closely  resembles  the  external 
genitals  of  the  female  (hypospadias  vulviforme),  and  that  errors  in 
sex  may  be  easily  made  at  birth  from  a  superficial  examination.  In 
cases  of  doubt  a  rectal  examination  should  be  made  to  establish  the 
presence  or  absence  of  a  uterus  and  its  adnexa.  Even  with  a  rectal 
examination  the  findings  are  often  vague,  and  in  extreme  cases  it 
is  impossible  to  determine  the  sex.  Hermaphrodites  are  in  the 
majority  of  cases  really  pseudohermaphrodites  of  the  male  sex 
affected  with  perineoscrotal  hypospadias. 

Functional  Disturbances.- — Functional  disturbances  vary  accord- 
ing to  the  position  of  the  abnormal  opening,  and  affect  the  functions 
of  micturition  and  generation.  In  hypospadias  of  the  glans  func- 
tional disturbances  are  less  serious,  although  the  orifice  may  be  so 
small  as  to  cause  retention  and  its  attending  complications.  The 
stream  of  urine  is  usually  projected  forward  and  is  not  scattered 
over  the  scrotum.  Coitus  and  fecundation  are  possible. 

In  other  varieties — penile,  penoscrotal,  and  scrotal — the  urine  is 
scattered  over  the  neighboring  parts,  soiling  the  clothes,  and  pro- 
ducing a  disagreeable  erythema.  In  order  to  pass  the  urine  to  the 
best  advantage  these  patients  assume  the  squatting  position  like 
women.  Coitus  is  usually  impossible,  and  even  when  possible 
fecundation  is  improbable.  It  is  obvious  that  subjects  affected  with 
perineoscrotal  hypospadias  are  capable  of  alternately  playing  the 
role  of  either  male  or  female. 

Treatment. — The  object  to  be  attained  is  the  restitution  of 
normal  anatomical  conditions  by  freeing  the  penis,  reconstructing 
the  urethra  and  imbedding  it  below  the  skin  surface.  This  is  ac- 
complished by  a  series  of  plastic  operations. 

INDICATIONS  FOE  OPERATION. — If  the  opening  is  so  small  that 
retention  is  imminent  it  should  be  freely  incised  to  avoid  the  conse- 
quences of  stricture,  otherwise  hypospadias  requires  no  immediate 
operative  treatment.  In  the  milder  cases  where  the  orifice  is  of 


HYPOSPADIAS  555 

normal  dimensions  and  is  situated  near  the  normal  tneatus  no  opera- 
tion is  required.  In  cases  of  balanitic  hypospadias  where  the  orifice 
is  at  the  base  of  the  glans,  or  a  short  distance  away,  operation  should 
be  considered,  but  not  before  the  child  is  four  years  of  age.  This 
variety  of  hypospadias  is  best  corrected  by  the  operation  of  Beck. 
In  restoring  the  penile  urethra  various  plastic  methods  may  be 
used,  and  the  ultimate  result  is  attained  only  by  operating  in  dif- 
ferent stages. 

In  the  scrotal  variety  of  hypospadias  surgical  treatment  can  ac- 
complish nothing.  In  all  operations  for  hypospadias  the  prognosis 
can  never  be  assured.  Time,  patience,  and  surgical  ingenuity  will 
often  accomplish  satisfactory  results,  but  under  the  most  favorable 
circumstances  the  prognosis  is  conjectural. 

OPERATIONS. — Beck's  Operation  for  Balanitic  Hypospadias. — 
This  procedure  is  described  by  Beck  as  "a  forward  dislocation  of 
the  urethra.  In  place  of  forming  a  new  urethra  the  existing  one 
is  utilized  by  dissecting  it  free  and  dislocating  it  forward,  so  that  a 
new  canal  does  not  need  to  be  created,  the  existing  urethra  perform- 
ing its  function."  This  operation  utilizes  the  elasticity  of  the 
urethra,  which  can  be  stretched  to  a  considerable  degree  without 
injury.  The  operation  is  conducted  as  follows:  The  urethra  is 
first  exposed  by  two  lateral  skin  flaps.  (Fig.  212  A.)  The  urethra 
is  dissected  out  and  isolated  from  the  surrounding  parts  for  about 
an  inch — so  that  it  can  be  drawn  to  the  extremity  of  the  glans 
without  difficulty.  The  glans  is  transfixed  with  a  iiarrow-bladed 
knife  from  base  to  tip.  (Fig.  212B.)  The  loosened  urethra  is  pulled 
through  the  new  canal  (Fig.  212C)  and  fixed  to  the  edges  of  the 
opening  by  four  silk  sutures.  The  skin  flaps  are  sutured  in  position. 
(Fig.  212D.) 

In  penile  or  penoscrotal  hypospadias,  whatever  plastic  procedure 
is  chosen,  the  first  step  consists  in  freeing  the  penis  from  any  exist- 
ing adhesions,  and  correcting  curvatures.  For  until  the  penis  is 
straight  and  able  to  lie  on  the  anterior  abdominal  wall  no  opera- 
tion for  forming  a  new  urethral  canal  should  be  attempted. 

After  straightening  the  penis  the  new  canal  may  be  formed  by 
various  plastic  procedures.  The  authors  consider  Rochet's  opera- 


556 


EPISPADIAS  AND  HYPOSPADIAS 


tion  for  penile  hypospadias  and  Bucknall's  operation  for  penoscrotal 
hypospadias  as  the  easiest  and  most  rational  procedures. 


FIG.  212. — BECK'S  OPERATION.     (After  Beck.) 

A.  Incisions  for  exposing  urethra;  B.  Tunneling  of  glans  penis;  C.  The  loosened  urethra 
drawn  through  the  new  canal;  D.  Flaps  sutured  in  position. 

Rochet's  Operation. — A  transverse  incision  is  made  in  front  of 
the  hypospadiac  opening  and  a  subcutaneous  channel  is  tunneled  by 


HYPOSPADIAS 


557 


means  of  a  blunt  instrument  to  the  base  of  the  glans.  A  meatus  is 
formed  by  making  a  transverse  slit  in  the  glans  and  the  blunt 
instrument  is  passed  on  to  the  opening  in  the  glans  (Fig.  213A).  The 
channel  thus  tunneled  is  prepared  to  receive  the  newly  formed 
urethra,  which  is  made  by  taking  a  flap  from  the  scrotum  with  its 
base  at  the  hypospadiac  orifice.  This  flap  with  the  skin  surface 
turned  in  is  sutured  about  a  ^To.  21  French  catheter  (Fig.  213B). 
The  catheter  thus  covered  with  the  skin  flap  is  drawn  through  the 
previously  prepared  channel  and  the  edges  of  the  newly  formed 
urethra  are  sutured  to  the  new  meatus  (Fig.  213C).  The  catheter 


FIG.  213. — ROCHET'S  OPERATION. 

A.  Tunneling  of  penis  and  glans;  B.  Skin  flap  sutured  around  catheter;  C.  Newurethral 
canal  reversed  and  drawn  through  tunnel  to  tip  of  penis.   (Rochet.) 

is  pushed  into  the  bladder  and  retained.  The  raw  surface  is  covered 
by  approximating  the  skin  edges  with  sutures.  (Fowler's  Surgery.) 

BucJcnall's  operation,  as  described  by  J.  K.  Murphy,  is  as 
follows  (Fig.  214)  : 

"First  Stage:  The  penis  is  first  drawn  up  over  the  abdomen 
and  kept  in  position  while  the  scrotum  is  stretched  downward.  Two 
vertical  incisions  are  now  made  on  either  side  of  the  middle  line 
of  the  penis  and  scrotum ;  these  should  be  about  a  quarter  of  an  inch 
apart,  and  are  so  arranged  that  the  position  of  the  urethral  orifice  is 
in  the  mid  part  of  the  median  strip  of  skin  thus  defined  (Fig.  214A). 
This  median  strip  will  form  the  new  urethra;  its  penile  portion, 


558 


EPISPADIAS    AND    HYPOSPADIAS 


or  that  in  front  of  the  meatus, 
part,  or  that  behind  the  meatus, 


FIG.  214. — BUCKNALL'S  OPERATION 
FOR  PENOSCROTAL  HYPOSPADIAS. 
(Burchard.) 

A.  The  vertical  and  horizontal  inci- 
sions for  the  flaps;  B.  Flaps  dis- 
sected up  and  turned  back ;  C.  The 
penis  secured  to  the  scrotum; 
D.  Flaps  sutured  together  and 
sutures  tied  over  small  piece  of 
drainage  tube;  E.  New  urethra 
closed  in  by  flaps  dissected  from 
the  scrotum ;  F.  Raw  area  closed 
by  suturing  edges  of  skin. 


is  to  form  the  roof;  and  its  scrota! 
the  floor.  At  either  ends  of  the  two 
longitudinal  incisions,  lateral  in- 
cisions are  now  made  outward  for 
about  a  quarter  of  an  inch,  and  two 
lateral  flaps  are  now  dissected  up 
from  end  to  end  of  the  lateral  in- 
cisions. These  should  be  of  the 
same  thickness  throughout.  They 
are  now  turned  back,  and  we  have 
now  the  stage  reached  in  Fig.  21-4B, 
which  shows  the  central  line  of  skin 
to  form  the  new  urethra,  and  the 
new  surfaces  on  either  side  formed 
by  the  lateral  flaps  turned  back. 

"A  soft  rubber  catheter  is  now 
passed  into  the  meatus  for  about 
half  an  inch,  and  then  laid  along 
the  lower  half  of  the  median  strip 
of  skin. 

"All  is  now  ready  for  the  next 
stage.  In  this  the  upper  half  of 
the  strip  of  skin  is  brought  down 
over  the  catheter  with  the  penis  to 
form  the  roof  of  the  urethra.  Thus 
the  penis  is  brought  down  into  con- 
tact with  the  scrotum  as  in  Fig. 
214C;  each  lateral  flap  is  bent  on 
itself  at  the  middle  to  form  a  broad 
edge  on  each  side.  The  flaps  must 
be  carefully  sutured  together  in 
such  a  way  that  each  suture  takes 
in  not  only  the  outer  skin  edges, 
but  approximates  the  skin  edges 
which  are  to  form  the  urethra 
round  the  catheter.  The  method 


IMPERFORATE    HYMEX  559 

is  shown  in  Fig.  214D.  Five  or  six  fine  sutures  are  put  in  on  each 
side  and  tied  over  a  small  piece  of  drainage  tube.  The  catheter  is 
now  secured  by  a  suture  and  made  to  drain  into  a  bottle.  The 
catheter  is  left  in  for  a  week  and  the  sutures  removed  about  the 
same  time. 

"Second  Stage:  It  now  only  remains  to  free  the  penis  from  its 
position  fixed  to  the  front  of  the  scrotum,  and  to  provide  a  skin 
covering  for  its  under  surface.  This  final  result  is  obtained  by 
making  an  incision  on  the  scrotum  as  in  Fig.  214E.  These  incisions 
should  be  some  way  distant  from  the  penis  on  either  side,  so  as  to 
provide  a  flap  wide  enough  to  cover  its  under  surface  without  ten- 
sion. These  flaps  are  now  dissected  up  from  the  scrotum,  care 
being  taken  not  to  injure  the  new  urethra  at  the  root  of  the  penis. 
The  flaps  are  now  sutured  together  on  the  under  surface  of  the 
penis,  as  in  Fig.  214E,  and  the  raw  surface  on  the  scrotum  obliter- 
ated by  bringing  the  edges  together  as  in  Fig.  214F. 

This  operation  is  ingenious  and  most  effectively  meets  the 
anatomical  requirements;  it  is  therefore  freely  quoted. 


CHAPTEE  LXYIII 

MALFOEMATIONS    OF   THE    FEMALE    GENITALS 

There  are  various  minor  malformations  of  the  female  genitals, 
such  as  hypertrophy  of  the  labia  minora,  hypertrophy  of  the  clitoris, 
which  may  demand  amputation.  We  also  find  that  hypospadias  and 
epispadias  occur  in  the  female,  though  they  are  much  more  rare 
than  in  the  male.  The  treatment  requires  suitable  plastic  opera- 
tions similar  to  those  described  for  the  male  genitals. 

Imperforate  Hymen. — The  malformations  of  real  clinical  im- 
portance, however,  are  the  imperf 'orations  of  the  hymen,  vagina,  and 
uterine  canal.  The  important  fact  is  that  there  are  usually  no  ex- 
ternal evidences  of  these  defects  and  they  remain  unrecognized  until 
puberty  and  the  establishment  of  the  menstrual  flow. 

At  this  time  there  appear  sharp  colicky  pains,  the  exact  cause 


500      MALFORMATIONS  OF  THE  FEMALE  GENITALS 

of  which  is  at  first  not  recognized.  These  painful  crises  show  a 
periodic  character  corresponding  to  the  menstrual  epoch. 

They  become  more  and  more  intense,  with  some  peritoneal  re- 
action, and  finally  a  fluctuating  tumor  may  appear  above  the  pubis 
and  menace  life  by  its  possible  rupture.  The  gradual  collection  of 
menstrual  fluid  distends  vagina,  uterus,  and  tubes,  and  unless  re- 
lieved may  rupture  into  the  peritoneal  cavity  and  be  followed  by 
peritonitis. 

A  history  of  periodic  pain  beginning  at  puberty  without  men- 
strual flow  should  suggest  an  examination  of  the  genitals.  If  the 
hymen  is  imperforate  it  should  be  incised  and  dilated  under 
anesthesia.  If  the  vagina  is  imperforate  an  effort  should  be  made 
to  incise  the  septum  and  to  establish  a  permeable  canal  by  the 
passage  of  bougies. 

In  extreme  cases  hysterectomy  may  be  required. 


SECTION  XIII 

THE    UPPER    EXTREMITY 

CHAPTER  LXIX 

CONGENITAL    MALFOKMATIONS    OF     THE    EXTREMITIES 

ABSENCE  OF  EXTREMITIES 

There  may  be  a  more  or  less  complete  absence  of  one  or  more 
of  the  extremities  or  of  their  segments.  These  malformations  may 
be  grouped  in  three  divisions. 

Ectromely. — Ectromely  refers  to  the  complete  absence  of  one  or 
more  extremities.  Sometimes  all  four  extremities  are  missing. 
More  frequently  it  affects  either  the  two  upper  extremities  or  the 
two  lower  extremities.  Rarely  is  the  malformation  confined  to  a 
single  limb.  Curious  anomalies  are  observed,  such  as  the  formation 
of  a  stump  terminating  in  one  or  more  digits,  or  a  stump  without 
any  appendage. 

Hemimely. — Here  the  distal  segment  of  one  or  more  extremities 
is  missing  or  exists  in  a  rudimentary  state — the  limb  terminates  in 
a  stump,  at  the  extremity  of  which  are  sometimes  appended  im- 
perfectly developed  fingers  or  foes.  Hemimely  sometimes  affects 
all  the  limbs,  or  again  only  a  single  limb  is  involved. 

Phocomely. — In  this  malformation  the  upper  segments  of  the 
limb  are  absent  and  the  distal  segments — hands  or  feet — are  directly 
attached  to  the  trunk.  It  usually  affects  the  entire  two  upper  or 
two  lower  limbs.  It  is  rarely  found  in  a  single  extremity. 

Etiology. — The  etiology  of  these  malformations  is  explained  by 
a  more  or  less  complete  arrest  of  development  of  the  various  seg- 
ments which  form  the  limb,  perhaps  by  intrauterine  amputations. 

561 


562  THE  SHOULDER 

A  biological  as  well  as  traumatic  origin  combines  to  bring  about 
these  defects. 

Treatment. — Amputation  of  useless  appendages  that  interfere 
with  the  application  of  some  prosthetic  apparatus,  and  some  form 
of  artificial  extremity  to  improve  function. 


CONGENITAL  GROOVES 

Congenital  grooves  are  transverse  or  oblique  circular  grooves 
found  on  the  fingers,  toes,  forearm,  or  leg;  rarely  on  the  superior 
segment  of  the  limbs.  These  grooves  affect  more  or  less  profoundly 
the  soft  tissues  and  may  compromise  the  continuity  of  the  limb. 
It  is  not  irrational  to  consider  them  the  first  stage  of  a  congenital 
amputation. 


CHAPTER  LXX 

THE    SHOULDER 

CONGENITAL  ELEVATION  OF  THE  SCAPULA 

Clinical  Picture. — This  congenital  high  position  of  the  scapula 
is  recognized  by  the  evident  asymmetry  of  the  two  scapulae.  One 
of  them  is  displaced  upward,  and  at  the  same  time  it  appears  to 
rotate  around  a  sagittal  axis  (Fig.  215).  Not  only  is  there  a  dis- 
placement, but  the  scapula  is  deformed  by  the  abnormal  traction  of 
the  muscles  acting  under  conditions  which  modify  their  function. 
Thus  the  superior  border  is  curved  forward  like  a  hook,  giving  the 
impression  of  an  exostosis. 

The  head  is  turned  toward  the  affected  side  with  marked  scoliosis 
of  the  neck  and  a  compensatory  dorsal  curve  of  the  spinal  column. 

These  secondary  changes  in  the  position  of  the  head  and  spinal 
column  vary  in  different  cases,  but  are  always  associated  with  diffi- 
culty in  raising  the  arm  to  a  horizontal  position  because  of  the  dis- 


FRACTURE    OF    THE    CLAVICLE 


563 


turbed  balance  of  those  muscles  which  move  the  shoulder  girdle  on 
the  plane  of  the  thorax. 

Etiology. — The  etiology  of  this  deformity  is  obscure.  It  must 
be  regarded  as  a  development 
defect.  It  is  often  accom- 
panied by  other  malforma- 
tions. Some  authors  have  at- 
tributed the  high  position  of 
the  scapula  to  a  bony  bridge 
which  connects  it  with  one  of 
the  vertebra?.  Its  removal 
has  been  attended  with  good 
results. 

Treatment. — Examine  the 
case  with  X-ray  to  detect  any 
bony  connection  between  the 
scapula  and  the  spine.  The 
existence  of  such  a  bony 
bridge  indicates  operative 
interference.  The  secondary 

symptoms — wry-neck  and  scoliosis — must  be  relieved  by  appropriate 
mechanical  treatment. 


FIG.    215. — CONGENITAL   ELEVATION  OF  THE 
SCAPULA.  (Kirmisson.) 


FRACTURE   OF  THE  CLAVICLE 

Fracture  of  the  clavicle  is  very  frequent  in  children  under  ten 
years  of  age.  The  mechanism  which  in  an  adult  would  result  in 
dislocation  of  the  shoulder  produces  a  fracture  of  the  clavicle  in 
children — a  fall  upon  the  shoulder  or  extended  hand ;  or  it  may  be 
produced  during  labor.  (See  Intrapartum  Fracture,  p.  248.) 
The  point  of  fracture  is  usually  at  the  weakest  part  of  the  clavicle 
— the  junction  of  the  outer  and  middle  thirds.  As  a  rule  it  is 
either  incomplete  (green-stick)  or  complete  but  subperiosteal. 

Symptoms  are  often  obscure  since  we  do  not  get  the  characteristic 
attitude  or  the  displacement  presented  in  the  adult.  The  character 


564  THE  SHOULDEK 

of  the  fracture  is  such  that  there  is  no  crepitation  or  abnormal 
mobility.  We  note  only  that  there  is  pain  when  the  arm  is  moved 
and  that  the  child  is  disposed  to  keep  the  arm  at  rest. 

Rule. — When  following  a  fall  upon  the  shoulder  a  child  ex- 
hibits pain  on  movement  of  the  arm,  or  refuses  to  move  it  volun- 
tarily, suspect  fracture  of  the  clavicle. 

Many  of  these  cases  are  brought  to  the  surgeon  some  time  after 
the  injury  because  the  parents  have  noticed  a  circumscribed  swell- 
ing over  the  seat  of  fracture,  which  indicates  the  formation  of 
callus. 

Treatment. — There  being  no  displacement,  reduction  is  unneces- 
sary and  it  is  only  essential  to  keep  the  parts  at  rest  by  placing  the 
arm  in  a  sling  and  fixing  the  arm  to  the  trunk  by  a  few  turns  of  a 
plaster  bandage.  At  the  end  of  two  weeks  the  arm  may  be  placed 
in  a  sling  outside  the  clothes  for  an  additional  week. 


CONGENITAL  DISLOCATION  OF  THE  SHOULDER 

Congenital  dislocation  of  the  shoulder  is  extremely  rare.  When 
it  occurs  it  is  probably  due  to  injury  contracted  during  delivery,  and 
is  often  associated  with  injury  to  the  brachial  plexus. 

Treatment* — Endeavor  to  reduce,  and  maintain  the  head  in  its 
proper  position  by  some  fixation  apparatus;  otherwise  operative 
treatment  will  be  necessary  to  avoid  functional  impairment. 


TUBERCULOSIS  OF  THE  SHOULDER 

Tuberculosis  of  the  shoulder  is  rare.  The  pathology  is  that  of 
tuberculous  joint  disease  in  general  (see  Tuberculosis  of  the  Joints, 
p.  205).  Though  the  fungus  form  is  more  usual,  there  is  a  tendency 
in  the  shoulder  for  the  disease  to  assume  the  dry  or  atrophic  form. 
Caries  sicca  is  a  dry  osteoarthritis  of  the  head  of  the  humerus  in 
which  there  is  destruction  of  bone  and  synovial  membrane  terminat- 
ing in  ankylosis. 


TTTBEKCTJLOSIS    OF    THE    SHOULDER  565 

Symptoms. — In  the  fungus  form  the  joint  capsule  is  filled  with 
granulations  and  the  overlying  deltoid  appears  swollen,  giving  an 
undue  prominence  to  the  shoulder.  In  the  dry  form  the  deltoid  is 
atrophied  from  disuse  and  the  shoulder  is  flattened.  There  is  pain 
on  pressure  over  the  humeral  head  or  on  motion,  and  function  is 
thereby  compromised.  The  arm  is  held  in  a  position  of  adduction 
and  slight  inward  rotation. 

Limitation  of  movement  in  the  shoulder  joint  must  be  carefully 
considered  with  a  due  regard  to  a  possible  source  of  error,  for  it 
will  be  recalled  that  limitation  of  movement  in  the  joint  itself  is 
often  masked  by  compensatory  rotation  of  the  scapula. 


FIG.  216. — ANKYLOSIS  OF  THE  SHOULDER-JOINT. 

Note  that  when  the  arm  is  in  a  horizontal  position  a  right  angle  is  formed  with  the  scapula 
in  the  normal  joint;  an  acute  angle  in  the  ankylosed  joint. 

Note  in  Fig.  216  that  when  the  arm  is  in  a  horizontal  position 
a  right  angle  is  formed  with  the  scapula,  but  when  the  joint 
is  ankylosed  it  forms  an  acute  angle  due  to  the  compensatory 
rotation  of  the  scapula.  Hence,  in  judging  defective  mobility  of  the 
shoulder  joint,  the  surgeon  should  observe  these  movements  from  be- 
hind, and,  after  immobilizing  the  scapula  with  one  hand,  note  whether 
normal  movements  of  the  joint  cause  the  scapula  to  rotate.  When 
the  caseating  mass  suppurates  the  pus  breaks  through  the  capsule, 
finds  its  way  along  the  bicipital  groove,  where  it  may  present  be- 
neath the  anterior  or  posterior  border  of  the  deltoid,  or  in  the  axilla, 
or  beneath  the  scapula ;  and  at  these  various  points  subsequent 
fistulse  may  be  established.  The  axillary  glands  are  always  involved. 


566  THE  SHOULDER 

Diagnosis. — Chronic  swelling  in  'the  shoulder  joint  of  a  child 
should  always  arouse  suspicion.  The  von  Pirquet  reaction  and  use 
of  the  X-ray  will  materially  aid  in  reaching  a  conclusion.  Sul>- 
deltoid  hursitis  may  present  a  clinical  picture  which  simulates  the 
dry  form  of  tubercular  arthritis,  but  in  bursitis  joint  movements 
are  not  essentially  obliterated  and  an  examination  under  ether  will 
remove  any  doubt.  Osteosarcoma  may  superficially  simulate  the 
fungus  form,  but  the  difference  in  the  clinical  picture  and  the 
X-ray  will  settle  this  question. 

Prognosis, — The  outcome  of  this  disease  in  its  most  favorable 
aspect  presents  two  important  considerations: 

(a)  Healing  of  the  joint  is  followed  by  loss  of  function  except 
in  those  rare  cases  where  there  is  a  hydrops  of  short  duration. 

(b)  There  is  usually  considerable  shortening  of  the  extremity 
due  to  destruction  of  the  epiphyseal  cartilage. 

It  is  well  to  remember  that  proximity  of  the  lung  adds  the  grave 
danger  of  its  involvement  in  the  process. 

Treatment. — GENERAL,  TREATMENT  is  that  of  joint  tuberculosis 
(see  p.  207). 

LOCALLY  the  treatment  should  be  along  conservative  lines  with 
special  reference  to  immobilization  of  the  joint  in  a  position  most 
favorable  to  function. 

Abscess  formation  demands  aspiration,  the  contents  removed  by 
suction,  and  the  injection  of  a  five  per  cent,  emulsion  of  iodoform 
and  glycerin,  or  a  two  per  cent,  emulsion  of  formalin  and  glycerin. 

Immobilization  of  the  shoulder  joint  cannot  be  obtained  by 
simply  placing  the  shoulder  in  a  plaster  cast.  Kirmisson's  rule 
should  be  followed,  viz. :  "We  should  include  to  a  very  large  extent 
the  cervical  region,  for  we  can  fix  the  joint  properly  only  by  making 
our  plaster  apparatus  reach  up  even  to  the  occiput  and  mastoid 
region  of  the  affected  side,  or  by  taking  it  over  to  the  cervical  region 
of  the  opposite  side." 

Resection  of  the  shoulder  joint  is  rarely  to  be  considered  in  chil- 
dren since  removal  of  the  epiphysis  results  in  permanent  shortening, 
and  even  ankylosis  of  the  shoulder  joint  is  not  attended  by  serious 
functional  impairment  since  there  are  ample  compensatory  move- 


TUBERCULOSIS    OF    THE    ELBOW  5(57 

ments  of  the  shoulder  girdle.  The  forcible  breaking  up  of  a  shoul- 
der ankylosis  under  anesthesia  is  a  dangerous  procedure,  since  it 
invites  a  recurrence  of  the  disease  in  a  latent  focus. 


CHAPTER  LXXI 


CONGENITAL  DISLOCATION  OF  THE  ELBOW 

Congenital  dislocation  of  the  elbow  occasionally  occurs,  al- 
though the  lesion  most  frequently  observed  is  an  isolated  dislocation 
of  the  head  of  the  radius.  There  is  frequently  observed  in  these  de- 
formities a  bony  bridge  connecting  the  radius  and  ulna,  the  radius 
remains  in  pronation  as  in  the  quadrupeds,  showing  that  we  are 
dealing  with  a  developmental  defect.  The  function  of  the  elbow 
is  seriously  compromised  by  the  deformity.  The  hand  is  per- 
manently pronated  and  cannot  be  completely  flexed  at  the  elbow. 

Treatment. — Removal  of  the  obstructions  to  motion.  An  X-ray 
will  determine  the  character  of  the  deformity  and  the  existence  of 
abnormal  bony  connections.  Resection  of  the  head  of  the  radius 
is  obviously  indicated  when  it  obstructs  free  movements  of  the 
forearm. 


TUBERCULOSIS   OF   THE   ELBOW 

The  elbow  is  the  joint  of  the  upper  extremity  in  which  the  tuber- 
culous process  is  most  frequently  manifest.  It  appears  mostly  in 
the  osseous  form,  the  foci  appearing  usually  in  the  external  condyle 
of  the  humerus,  often  in  the  olecranon,  and  rarely  in  the  head  of 
the  radius.  The  disease  spreads  from  its  primary  focus,  filling  the 
joint  with  granulation  tissue  which  follows  the  typical  process  of 
caseation,  suppuration,  and  fistulization. 

Symptoms. — Pain,     swelling,     gradual    fixation,     and    muscular 


568  THE  ELBOW 

atrophy.  The  joint  loses  its  normal  contour  and  acquires  a  spindle- 
shaped  form. 

The  joint  being  most  superficial  posteriorly,  we  note  an  oblitera- 
tion of  the  normal  grooves  on  each  side  of  the  olecranon,  and  later, 
when  abscess  discharges,  fistulous  openings  are  formed  on  either 
side  the  triceps  tendon. 

As  the  disease  progresses  the  joint  assumes  a  characteristic 
vicious  attitude — it  is  fixed  in  a  position  of  slight  flexion  combined 
with  marked  pronation.  It  is  evident  that  this  position  incapaci- 
tates the  arm  for  ordinary  service,  since  the  hand  can  neither  reach 
the  mouth  nor  head.  There  is  usually  involvement  of  the  epitroch- 
lear  and  axillary  glands. 

Diagnosis  offers  little  difficulty.  The  history  and  X-ray  will  dif- 
ferentiate similar  clinical  pictures.  Osteosarcoma  is  rarely  found 
in  the  elbow  joint. 

Treatment. — General  treatment  is  that  of  joint  tuberculosis  (see 
p.  207).  Sometimes  the  X-ray  will  demonstrate  that  the  disease 
is  extraarticular,  and  it  may  then  be  possible  to  open  the  bone 
abscess  outward  and  thus  prevent  it  from  breaking  through  into 
the  joint. 

When  the  joint  is  involved,  immobilize  in  plaster  cast  in  the 
position  of  greatest  functional  value,  which  is  a  position  of  such  pro- 
nounced flexion  and  supination  that  the  palmar  surface  of  the  hand 
can  easily  reach  the  mouth.  Immobilization  should  continue  until 
three  months  after  all  inflammatory  phenomena  have  disappeared. 

The  blood  supply  to  the  diseased  area  should  be  increased  by 
producing  an  artificial  chronic  congestion  after  the  method  of  Bier. 

Abscess  formation  demands  aspiration,  removal  of  contents  by 
suction,  and  the  injection  of  a  five  per  cent,  emulsion  of  iodoform 
and  glycerin,  or  a  two  per  cent,  emulsion  of  formalin  and  glycerin. 
Otherwise  the  treatment  is  conservative.  Healing  of  the  tubercular 
process  usually  results  in  ankylosis,  or  untreated  the  disease  pro- 
gresses to  suppuration  and  fistulization.  In  both  of  these  conditions 
operative  measures  must  be  considered. 

Do  not  resort  to  resection  of  the  elbow  in  young  children  unless 
there  are  pronounced  vital  or  functional  indications.  Resection  of 


FRACTURES   AT   THE    ELBOW  569 

the  elbow  in  children  is  attended  with  arrest  of  growth  in  the  limb 
and  often  flail  joint.  If,  therefore,  there  is  ankylosis  in  good  func- 
tional position  it  is  the  part  of  wisdom  to  be  satisfied  with  a  fairly 
useful  though  deformed  arm.  If,  on  the  other  hand,  there  is  anky- 
losis  in  such  faulty  position  that  function  is  seriously  impaired, 
resection  of  the  joint  is  indicated. 

Resection  and  arthrectomy  must  be  resorted  to  in  those  extreme 
cases  where  continued  suppuration  and  fistulization  make  the  indi- 
cations vital. 


FRACTURES  AT  THE  ELBOW 

As  Kirmisson  has  remarked,  "Fractures  of  the  elbow  are  par 
excellence  the  fractures  of  childhood."  Not  only  their  frequency 
but  their  gravity  lays  a  heavy  burden  of  responsibility  upon  every 
practitioner.  For  these  fractures  imperil  the  function  of  the  joint, 
and  the  usefulness  of  the  limb  is  at  stake.  In  childhood  the  elbow 
is  a  center  of  traumatism  because  it  is  a  point  of  diminished  re- 
sistance. The  lower  extremity  of  the  humerus,  with  which  the 
bones  of  the  forearm  are  in  intimate  relation,  is  in  process  of  de- 
velopment and  ossification — it  is  an  unfinished  product,  and  as  yet 
unprepared  to  offer  resistance  to  an  unusual  strain.  But  the  unusual 
strain  is  frequent  in  childhood  as  an  instinctive  means  of  defense 
and  protection;  when  the  child  falls  the  arms  are  naturally  pro- 
jected in  front  and  interposed  between  the  body  and  the  ground; 
the  shock  transmitted  from  the  ground  to  the  shoulder  is  centered 
at  the  elbow,  in  great  part  upon  the  lower  extremity  of  the  humerus, 
and  the  articular  surface  is  not  only  broken  but  the  fragments 
usually  dislocated,  so  that  consequences  singularly  complex  are  the 
result. 

Hero,  then,  is  a  joint  of  great  functional  importance  presenting 
a  lesion  of  great  complexity.  The  problem  is  not  a  simple  one, 
since  it  involves  a  reduction  that  not  only  restores  continuity  of 
the  fragments,  but  functional  activity  of  the  joint.  It  is  obvious 
that  in  the  fracture  of  a  long  bone  a  slight  discrepancy  of  the  frag- 


570 


THE  ELBOW 


ments  is  compatible  with  perfect  functional  result.  But  in  frac- 
ture of  the  elbow  even  slight  abnormal  prominence  in  the  interior 
of  the  joint  will  be  an  obstacle  to  the  normal  joint  movements,  and 
may  be  the  cause  of  a  permanent  infirmity. 

Again,  it  must  be  emphasized  that,  under  the  most  favorable  con- 
ditions of  treatment,  perfect  results  cannot  be  guaranteed;  the 
prognosis  must  always  be  guarded,  and  the  possibility  of  functional 
impairment  emphasized.  However,  the  best  results  can  be  obtained 
only  when  treatment  is  based  upon  exact  knowledge  of  the  mech- 
anism of  the  joint  and  of  the  dam- 
age caused  by  the  trauinatism; 
these  facts  are  the  only  safe  guides 
in  reducing  the  fragments  and 
maintaining  them  in  permanent 
position.  Exact  information  can 
be  obtained  only  by  means  of  the 
X-ray.  A  fracture  of  the  elbow 
should  not  be  subjected  to  treat- 
ment until  the  X-ray  has  demon- 
strated the  exact  lesion.  Proper 
reduction  of  the  fragments  is  only 
possible  when  the  patient  is  anes- 
thetized. No  other  course  is  per- 
missible except  this  is  rendered 
impossible  by  circumstances.  A 
fractured  elbow  requires  an  X-ray 
to  define  the  lesion,  an  anesthetic 
to  facilitate  reduction,  and  a  sec- 
ond X-ray  to  verify  the  accuracy  of  reduction. 

Anatomy  of  the  Elbow. — The  child's  elbow  is  not  a  miniature 
adult  elbow,  it  is  a  joint  formed  by  epiphyses  in  the  process  of  de- 
velopment. An  exact  knowledge  of  the  development  of  the  elbow 
is  necessary  to  properly  interpret  the  radiograph  and  reduce  the 
fragments.  The  surgeon  must  know  the  normal  before  he  can  inter- 
pret the  pathological ;  he  must  be  familiar  with  the  precise  situation 
of  the  centers  of  ossification  in  the  epiphyses,  their  form  and  value, 


FIG.   217. — RADIOGRAPH  OF  NORMAL 

ELBOW  AT  TEN  YEARS. 
Note  the  epiphyseal  centers  appear- 
ing as  detached  fragments. 


FKACTUKES   AT   THE    ELBOW 


571 


FIG.  218. — RADIOGRAPH  OF  NORMAL  ELBOW  AT 
Two  YEARS. 


and  how  they  look  in  the 
picture.  It  is  easy  to  mis- 
take a  conjoined  cartilage 
for  a  fracture  line,  or  a  cen- 
ter of  ossification  for  a  de- 
t  a  c  h  e  d  fragment  (Fig. 
217).  It  must  be  recalled 
that  until  the  end  of  the 
second  year  the  lower  end 
of  the  humerus  is  cartilagi- 
nous, no  centers  of  ossifi- 
cation have  as  yet  appeared 
(Fig.  218).  At  the  third 
year  the  diaphysis  pushes 
out  a  median  wedge-like 
prolongation  toward  the 
middle  of  the  epiphysis, 
which  gives  solidity  to  the 

inferior  extremity;  about  this  diaphyseal  prolongation  are  grouped 
the  four  centers  of  ossification  (Fig.  219).  The  first  center  of  ossi- 
fication to  appear  is  that  for 
the  capitellum  at  the  third 
year;  it  extends  inward  and 
forms  the  outer  half  of  the 
trochlear  surface.  The  centers 
for  the  inner  portion  of  the 
trochlear  and  for  the  external 
condyle  appear  at  the  twelfth 
year.  These  three  centers 
coalesce  and  form  an  epiphy- 
sis, which  unites  with  the 
shaft  at  about  the  sixteenth 
year.  The  fourth  center  for 

FIG.  219.-THE  FOUR  CENTERS  OF  OSSIFICA-   the     internal     epicondyle     ap- 
TION  FORMING  THE  LOWER  'EPIPHYSISOF 
THE  HUMERUS.  pears      at     about     the     fifth 

a,    the    capitellum;   b,    the    inner    epicondyle; 

c,  the    trochlea;    d,   the    outer    epicondyle.      year.        It     forms     a     Separate 


572  THE  ELBOW 

epiphysis,    and    unites    with    the    shaft    at    about    the    eighteenth 
year. 

It  will  be  noted  that  these  four  ossific  centers  may  be  naturally 
divided  into  two  distinct  groups : 

(a)  The  inferior  and  external  group,  consisting  of  the  external 
condyle,  capitellum,  and  trochlear,  which  coalesce  and  form  one  mass 
which  joins  the  shaft  about  the  sixteenth  year,  and 

(b)  The  internal  epicondyle,  which  joins  the  shaft  late,  rarely 
before  the  eighteenth  year,  and  sometimes  as  late  as  the  twenty-fifth 
year. 

This  anatomical  division  of  the  centers  has  an  important  bear- 
ing on  the  character  and  frequency  of  elbow  fractures. 

At  the  superior  extremity  of  the  ulna  the  olecranon  process  is  car- 
tilaginous. A  center  of  ossification  appears  about  the  ninth  year,  and 
this  epiphysis  unites  with  the  shaft  about  the  twentieth.  The  upper 
extremity  of  the  radius  is  capped  with  cartilage,  the  center  appears  at 
the  sixth  year  and  fuses  with  the  neck  about  the  age  of  eighteen. 

Etiology. — The  etiology  of  these  fractures  is  important  to  keep 
in  mind  because  of  the  clew  which  it  gives  to  diagnosis.  These 
fractures  are  rare  in  the  first  two  years,  since  at  this  period  the 
epiphyses  are  entirely  cartilaginous  and  act  as  elastic  buffers,  which 
transmit  blows  without  breaking;  besides  the  child  is  less  exposed 
to  traumatism.  They  are  most  frequent  during  the  developmental 
period  of  the  elbow,  which  is  between  the  third  and  fourteenth 
years.  Boys  are  naturally  more  exposed  than  girls  because  of  their 
activity. 

The  cause  of  these  fractures  is  significant.  They  are  rarely 
caused  by  sudden  traction  (sudden  traction  usually  causes  dislo- 
cation of  the  radial  head)  or  by  direct  violence.  Almost  uniformly 
there  is  the  history  of  an  indirect  blow  transmitted  to  the  articular 
extremities.  For  example,  the  child  falls  (rarely  from  an  elevated 
position),  it  instinctively  protects  itself  by  projecting  the  forearm 
in  front,  the  hand  conies  in  contact  with  the  ground,  and  the  shock 
is  transmitted  to  the  inferior  extremity  of  the  humerus,  which  frac- 
tures in  various  directions  according  to  the  position  of  the  arm.  The 
two  forces  then  are  the  weight  of  the  body,  transmitted  by  the 


FRACTUEES    AT    THE    ELBOW  573 

humerus,    and   the   resistance    of   the   ground,    transmitted    by    the 
radius. 

Diagnosis. — When  a  child  presents  itself  after  injury  to  the  elbow 
there  may  be  a  contusion  or  a  dislocation,  but  always  suspect 
fracture. 

Remember  that  supracondyloid  fracture,  without  displacement 
or  fracture  of  the  internal  condyle,  may  simulate  contusion  by  the 
absence  of  swelling  and  ecchymosis,  and  the  slight  interference  with 
function.  Even  when  careful  examination  points  to  contusion,  radio- 
graph the  elbow  lest  a  fracture  escape  unrecognized.  Whenever  the 
apparent  symptoms  point  to  dislocation  remember  that  a  simple  dis- 
location in  a  child  unaccompanied  by  fracture  is  rare.  Apparent 
dislocation  should  always  suggest  a  search  for  the  accompanying 
fracture.  The  X-ray  will  usually  reveal  an  osseous  lesion  of  which 
the  dislocation  is  but  a  symptom. 

METHOD  OF  EXAMINATION. — The  obstacles  in  the  way  of  a  thor- 
ough examination  are  many :  The  child  cannot  be  interrogated ;  the 
history  of  the  injury  cannot  be  obtained  at  first  hand;  the  surgeon 
must  rely  solely  on  his  own  ingenuity  in  interpreting  the  facts. 
These  facts  are  gleaned  principally  by  inspection  and  palpation ; 
but  the  child  resists  a  local  examination,  the  muscles  are  contracted, 
and  the  condition  thus  obscured;  hence  the  necessity  of  anesthesia, 
not  deep,  but  just  sufficient  to  relax  the  muscles  and  permit  free 
palpation. 

Never  hesitate  to  give  an  anesthetic  of  short  duration  for  the 
examination  of  every  elbow  injury. 

First,  inspect  the  elbow  and  note  the  localization  of  the  ecchy- 
mosis; if  it  surrounds  the  elbow  supracondyloid  fracture  may  be  sus- 
pected; if  it  is  localized  at  the  sides,  look  for  fracture  of  the 
condyles. 

Second,  palpate  the  parts:  Note  the  normal  anatomical  relations 
of  the  uninjured  elbow: 

(a)  The  Relation  of  the  Three  Bony  Points. — Place  the  thumb 
and  middle  fingers  on  the  internal  and  external  condyles  and  the 
index  finger  on  the  tip  of  the  olecranon.  When  the  forearm  is  fully 
extended  the  three  bony  points  lie  on  the  same  transverse  line 


574 


THE  ELBOW 


(Fig.  220).     Any  modification  of  the  normal  relations  of  the  three 
bony  points  is  due  to  fracture  or  dislocation. 

(b)  The  head  of  the  radius  can  be  felt  in  the  dimple  behind  the 
elbow.  Its  rotation  is  manifest  when  the  forearm  is  pronated  and 
supinated.  In  injuries  about  the  elbow  the .  determination  of  the 
position  of  the  radial  head  is  of  prime  importance. 


FIG.   220. — RELATION  OF  THE   THREE 
BONY  POINTS  OF  THE  ELBOW. 


FIG.  221. — THE  "  CARRYING  ANGLE" 
WHICH  THE  SUPINATED  FORE- 
ARM FORMS  WITH  THE  ARM. 


(c)  Compare  the  "carrying  angle"  of  the  two  arms — the  obtuse 
angle  which  the  extended  forearm  forms  with  the  arm  (Fig.  221). 
This  angle  is  modified  in  certain  fractures  of  the  elbow. 

(d)  Note  the  movement  of  the  elbow  joint,  both  flexion  and  ex- 
tension.    Remember  there  is  normally  no  lateral  motion  in  the  ex- 
tended elbow  joint. 

With  these  standards  of  comparison  the  injured  elbow  should 


FRACTURES    AT    THE    ELBOW  575 

be  carefully  palpated  and  the  presence  of  crepitus  and  other  abnor- 
malities determined.  These  palpations  should  be  conducted  in  a 
gentle,  delicate  manner,  nor  should  force  ever  be  used  sufficient  to 
exaggerate  the  lesion  and  destroy  the  valuable  periostea!  connections. 
The  aim  of  every  examination  is  precision  of  diagnosis.  This  can 
be  obtained  only  by  a  careful  methodical  clinical  examination  con- 
trolled by  the  X-ray. 

THE  VALUE  OF  X-RAY  EXAMINATION. — The  final  word  of  diag- 
nosis belongs  to  the  X-ray,  nor  should  it  ever  be  omitted  even  when 
the  injury  appears  trivial.  It  is  impossible  by  palpation  alone  to 
discover  all  the  details  of  a  fractured  elbow.  In  the  X-ray  we  have 
a  valuable  aid  in  making  a  precise  diagnosis.  We  do  not  believe 
the  X-ray  is  sufficient  of  itself,  nor  is  it  to  supplant  the  clinical 
examination,  or  relegate  it  to  a  second  place;  but  the  clinical  and 
radiographic  examination  taken  in  conjunction  each  interprets  the 
other.  After  thorough  palpation  the  X-ray  enables  us  to  correct 
errors;  to  confirm  a  diagnosis  already  made,  and  to  give  mathe- 
matical precision  to  our  conclusions;  and  finally  when  the  reduction 
is  made  and  the  retention  splint  applied  it  checks  the  final  error  of 
imperfect  reduction  and  retention. 

The  X-ray  picture  should  be  taken  and  interpreted  by  those  who 
possess  special  knowledge  and  experience.  An  amateur  X-ray  pic- 
ture of  an  injured  elbow  is  of  little  value.  However  good  the  picture 
it  is  valueless  unless  properly  interpreted.  As  already  stated  the 
child's  elbow  is  not  a  miniature  adult  elbow,  it  is  a  joint  in  the  pro- 
cess of  development — it  consists  of  osseous  regions,  cartilaginous 
regions,  and  centers  in  process  of  ossification;  its  parts  are  of  dif- 
ferent density — and  offer  a  different  resistance  to  the  penetration 
of  the  X-rays.  The  essential  factor  in  the  picture  is  detail,  hence 
the  necessity  of  using  soft  tubes.  In  radiographing  an  injured 
elbow  there  should  always  be  two  pictures  of  the  same  fracture,  a 
surface  radiograph  and  a  profile  radiograph  (Fig.  222). 

(a)  The  surface  radiograph  should  be  taken  with  the  arm  in 
complete  extension,  the  arm  resting  on  the  plate  on  its  posterior 
surface. 

(b)  The  profile  radiograph  should  be  taken  with  the  elbow  in 


576 


THE  ELBOW 


median  flexion,  the  hand  pronated  with  its  internal  surface  resting 
on  the  plate.  It  is  obvious  that  the  child  should  be  anesthetised  in 
order  that  the  proper  attitude  may  be  assumed  without  provoking 
pain. 

After  the  diagnosis  is  confirmed,  the  reduction  made,  and  the 
splint  applied,  a  second  X-raj  should  confirm  the  accuracy  of  the 
results. 

Prognosis. — The  prognosis  of  fracture  of  the  elbow  in  children 


FIG.  222. — SURFACE  AND  PROFILE  RADIOGRAPH  OF  A  STJPRACONDYLAR  FRACTURE. 
Note  the  value  of  the  profile  radiograph  in  showing  the  nature  of  the  injury. 

must  always  be  guarded ;  even  under  the  most  favorable  conditions 
of  treatment  perfect  results  cannot  be  guaranteed.  The  possibility 
of  some  functional  impairment  should  always  be  emphasized.  While 
the  process  of  ossification  in  the  child  is  very  rapid  because  of  the 
extreme  fertility  of  the  young  periosteum,  yet  consolidation  of  the 
fragments,  however  perfect,  is  compatible  with  a  very  imperfect 
functional  result. 

The  prognosis  of  these  fractures  depends  upon: 
(a)    Reduction — It    is    obvious    that    perfect    reduction    is    the 
prime  requisite  of  perfect  functional  results;  yet  it  is  well  to  keep 


577 

in  mind  the  difficulties  of  perfect  reduction  and  thus  be  guarded  in 
our  prognosis;  for  no  surgeon,  however  skilful,  can  guarantee  a  per- 
fect result  in  a  fracture  of  the  elbow,  however  simple.  There  are 
some  fractures  of  the  elbow  primarily  irreducible,  such  as  those  rare 
cases  of  impaction  where  surgical  intervention  may  be  necessary; 
or  there  may  be  interposition  of  the  fragment  in  the  joint  where  the 
interarticular  obstacle  opposes  reposition,  and  all  attempts  at  reduc- 
tion are  fruitless.  These  cases  left  to  themselves  inevitably  produce 
bad  results.  Immobilization  and  massage  can  have  but  one  result, 
viz.,  to  increase  articular  inflammation  and  forestall  complete 
ankylosis.  These  cases  must  be  relieved  by  surgical  intervention. 
Again,  we  find  a  certain  proportion  of  cases  where  the  fragment 
rotates  on  itself.  In  supracondyloid  fracture  the  fragment  may  so 
tilt  on  itself  that  reduction  is  impossible  and  surgical  intervention 
necessary  to  complete  a  cure. 

Finally,  there  are  cases  which  present  certain  difficulties  in  re- 
duction even  after  the  clinical  diagnosis  and  the  X-ray  have  con- 
firmed the  findings  and  reduction  seems  simple.  Such  cases  are 
those  with  very  small  fragments  and  great  swelling  (interarticular 
fracture  of  the  condyle  or  fracture  of  the  neck  of  the  radius).  The 
fragments  are  so  small  that  the  fingers  can  secure  little  hold,  espe- 
cially in  the  presence  of  much  swelling.  Reduction  by  direct 
pressure  is  often  impossible,  and  reduction  must  be  made  indirectly 
by  means  of  the  ligaments  in  exercising  traction  on  the  forearm. 
Many  of  these  cases  escape  unreduced  and  result  in  defective  con- 
solidation. 

(b)  Retention. — Even  after  reduction  is  satisfactorily  accom- 
plished it  is  necessary  to  retain  the  fragments  in  proper  position. 
It  must  be  remembered  that  many  fractures  after  reduction  have 
a  remarkable  tendency  to  secondary  displacement.  When  the  frag- 
ment is  reduced  it  may  be  easily  held  in  position  by  direct  pressure 
of  the  fingers,  but  when  we  substitute  for  the  pressure  thus  made 
immobilization  by  the  splint,  there  is  often  produced  a  displacement 
of  the  fractured  surfaces,  which  results  in  vicious  position. 

Again,  after  the  splint  has  been  on  for  a  few  days  the  swelling 
disappears  and  the  splint  no  longer  accurately  supports  the  frag- 


578  THE  ELBOW 

ments,  which  then  become  displaced.  Thus,  imperfect  retention  of 
the  fragments  may  result  in  abnormal  prominence  or  deviation  of 
the  forearm  (gun-stock  deformity)  or  in  impaired  function  (Destot, 
Vignard,  Barlatier). 

(c)  Exuberant  Callus. — This  is  specially  observed  in  fractures 
incompletely  reduced  or  badly  immobilized  and  may  be  a  grave  com- 
plication.    The  prognosis,  of  course,  is  variable,  depending  upon  the 
situation  and  the  volume  of  callus.     It  is  obvious  that  in  supracon- 
dyloid  fracture  the  callus  may  be  excessive  and  even  produce  de- 
formity without  interfering  with  articular  movements.     If,  however, 
it  is  situated  anteriorly  it  may  form  an  osteoma  of  considerable 
volume  and  thus  interfere  with  flexion.     If  the  fracture  is  inter- 
articular  the  prognosis  is  graver,   since  exuberant  callus  may  fill 
the  olecranon  and  coronoid  fossae  and  thus  interfere  with  flexion  and 
extension.     Again,  in  some  fractures  there  is  extensive  laceration  of 
the  periosteum  and  capsule,  as  well  as  detachment  of  the  ligaments. 

Exuberant  callus  is  usually  absorbed  if  the  fracture  is  recent 
and  immobilization  is  sufficiently  long.  In  old  fractures  the  prog- 
nosis is  bad  and  the  result  is  usually  complete  ankylosis. 

(d)  Arthritis. — In  all  fractures  involving  the  joint  traumatic 
arthritis  with  more  or  less  swelling  is  to  be  expected.      In  these 
cases  the  prognosis  depends  upon  the  articular  reaction.     In  such 
fractures  as  the  high  supracondyloid,  fracture  of  the  internal  epi- 
condyle,  the  joint  is  not  involved  and  the  prognosis  depends  entirely 
upon  accurate  reduction.    In  intra-articular  fracture,  however  (frac- 
ture of  one  of  the  condyles),  there  is  usually  a  hemarthrosis,  which 
either  absorbs  slowly  or  organizes  and  forms  fibrous  bands  which 
result  in  ankylosis. 

These  cases  require  nice  surgical  judgment  since  too  early 
mobilization  excites  inflammatory  reaction  and  mechanically  irri- 
tates the  periosteum,  while  too  long  immobilization  favors  organiza- 
tion of  the  exudate. 

Typical  Forms  of  Fracture  of  the  Elbow  in  Children. — The  chil- 
dren's types  of  fracture  at  the  elbow,  in  the  order  of  their  frequency, 
are: 

A.  SUPRACONDYLAR  FRACTURE  (Fig.  223). — The  mechanism  of 


FKACTUKES    AT    THE    ELBOW  579 

this  lesion  differs  in  no  essential  from  the  corresponding  lesion  in 
the  adult.  It  is  more  frequently  found  in  older  children  who  are 
exposed  to  severer  traumatism  and  in  whom  the  different  parts  of 
the  humeral  end  are  better  consolidated.  The  fracture  is  usually 
the  result  of  a  fall  upon  the  outstretched  hand,  the  hyperextended 
elbow  prying  off  the  lower  end  of  the  humerus.  (In  an  adult  this 
same  force  usually  produces  backward  dislocation  of  the  elbow.) 
The  line  of  fracture  is  just  above  the  epiphyseal  line,  as  a  rule 
directed  obliquely  upward  and  backward.  The  lower  fragment  is 
displaced  upward  and  backward  and  held  in  this  position  by  the 
strong  action  of  the  triceps.  The  overriding  fragments  cause  a  full- 


FlG.  223. — SUPBACONDYLAR  FRACTURE. 

ness  at  the  elbow  in  front,  producing  a  deformity  which  simulates  a 
backward  dislocation  of  the  elbow. 

(Rarely  there  may  be  a  supracondyloid  fracture  without  dis- 
placement, simulating  contusion  by  absence  of  swelling  and  the 
slight  interference  with  function.) 

Examination  of  this  lesion  is  difficult  because  of  the  swelling  and 
ecchymosis,  hence  anesthesia  is  essential.  Determine  the  position 
of  the  three  bony  points.  It  will  be  found  that  the  tip  of  the 
olecranon,  though  pulled  backward  and  upward,  maintains  its  rela- 
tive position — in  a  straight  transverse  line  with  the  epicondyles. 
In  backward  dislocation  the  tip  of  the  olecranon  is  above  the  trans- 
verse line  connecting  the  three  bony  points.  The  sharp  edge  of  the 


580 


THE  ELBOW 


upper  fragment  may  be  felt  in  the  fold  of  the  elbow  pressing 
against  the  soft  parts,  and  the  general  symptoms  of  fracture  are 
present  (deformity,  abnormal  mobility,  crepitus,  ecchymosis,  and 
loss  of  function).  Movements  of  flexion  and  extension  are  easily 
made  (in  sharp  contrast  to  dislocation).  Traction  upon  the  forearm 
while  the  humerus  is  fixed  reduces  the  deformity;  as  soon  as  the 
traction  is  relaxed  the  deformity  recurs.  The  value  of  the  X-ray 

is    obvious.        (For    treat- 
ment, see  p.  584.) 

B.  SEPARATION  OF  TILE 
LOWER  EPIPHYSIS  OF  THE 
HUMERUS. — Separation  of 
the  lower  epiphysis  of  the 
humerus  is  a  very  rare 
lesion  and  does  not  occur 
after  the  third  year.  The 
usual  cause  is  a  fall  on  the 
elbow  or  "jamming"  the  el- 
bow in  a  door. 

The  symptoms  are  sim- 
ilar to  those  of  supracon- 
dylar  fracture.  If  there  is 
slight  swelling  it  may  be 
possible  to  palpate  the 
wedge-shaped  lower  end  of 
the  diaphysis  and  the  cor- 
responding excavation  on 
the  upper  surface  of  the  epiphysis.  It  may  also  be  possible  to 
determine  the  "muffled  crepitus"  characteristic  of  epiphyseal  separa- 
tions. It  is  well  to  note  that  the  X-ray  will  show  no  displacement 
before  the  second  year,  since  the  epiphysis  at  this  period  is  carti- 
laginous and  permeable  to  the  rays. 

C.  FRACTURE  OF  THE  EXTERNAL  CONDYLE  (Fig.  224). — Frac- 
ture of  the  external  condyle  is  almost  as  frequent  as  supracoudylar 
fracture.  It  is  obvious  that  in  a  fall  on  the  palm  of  the  hand  the 
force  is  transmitted  directly  through  the  radius  to  the  outer  side  of 


FIG.  224. — FRACTURE  or  THE  EXTERNAL 
CONDYLE. 


581 


the  humerus ;  besides  the  process  of  ossification  is  much  slower  in 
the  external  than  the  internal  condyle.  These  factors  contribute  to 
its  frequency.  While  the  fracture  line  follows  the  general  course 
of  the  epiphyseal  line,  yet  it  is  usual  to  find  either  a  portion  of 
the  shaft  or  the  external  edge  of  the  trochlear  included  in  the 
fragment. 

The  functional  symptoms  are  those  of  fractures  at  the  elbow- 
pain  on  movement  and  complete  impotence. 

On  examination, 
swelling  and  ecchymosis 
are  noted  in  the  region  of 
the  outer  condyle,  if  the 
examination  is  made  sev- 
eral hours  after  the  in- 
jury. The  fragment  is 
usually  displaced  upward 
.and  outward,  producing 
a  well-marked  deformity, 
and  the  normal  relation 
of  the  three  bony  parts  is 
disturbed.  In  exploring 
the  elbow  the  superficial 
situation  of  the  fragment 
permits  satisfactory  pal- 
pation of  the  fragment, 
the  abnormal  mobility, 
and  crepitus.  In  comparing  the  two  forearms  placed  in  extension  it 
will  be  noted  that  there  is  often  a  deviation  of  the  injured  side,  pro- 
ducing the  deformity  known  as  cubitus  varus.  Pronation  and  supi- 
nation  are  always  possible  under  anesthesia,  and  forced  supination 
will  frequently  elicit  crepitus.  There  should  be  little  difficulty  in 
diagnosing  this  lesion  under  anesthesia.  Confirmation  by  the  X-ray 
is  important. 

D.  FRACTURE  OF  THE  INTERN AL  EPICONDYLE  (Fig.  225). — 
Fracture  of  the  internal  epicondyle  is  quite  commonly  observed  and 
is  usually  caused  by  a  direct  blow  or  fall  upon  the  inner  surface  of 


FIG.  225. — FKACTUBE  OF  THE  INTERNAL  EPICON- 
DTLE.  (Destot.) 


THE  ELBOW 

the  elbow.  The  fragment  is  small,  the  displacement  downward,  and 
the  joint  rarely  involved.  There  are  pain,  swelling,  and  ecchymosis 
over  the  fractured  region,  but  the  joint  movements  are  not  seriously 
impaired.  The  close  relation  of  the  ulnar  nerve  to  this  bony  process 
exposes  it  to  injury  as  a  complication  of  fracture.  In  some  cases  the 
fractured  fragment  had  to  be  removed  to  relieve  pressure  on  the  nerve 
(Poland).  The  symptoms  of  this  lesion  are  in  general  benign,  and 
unless  careful  examination  is  made  it  may  be  mistaken  for  contusion. 

It  must  be  remembered  that  fracture  of  the  internal  condyle  is 
sometimes  a  complication  of  elbow  dislocation  and  one  of  great  im- 
portance. Simple  dislocation  in  the  child  is  exceptional ;  it  is  usually 
associated  with  fracture  of  the  internal  epicondyle.  When  such  a 
lesion  is  present  it  may  assume  a  grave  aspect  by  the  fragment  being 
caught  between  the  joint  surfaces,  so  that  the  osseous  fragment  can- 
not be  recognized  by  palpation,  nor  can  movements  of  the  joint  be 
obtained  even  under  anesthesia. 

Fractures  of  the  internal  condyle,  as  well  as  of  the  olecranon 
and  the  radial  neck,  are  rare  in  children  and  differ  in  no  essential 
from  the  corresponding  lesions  in  the  adult. 

Treatment. — The  prime  consideration  in  the  treatment  of  frac- 
tures of  th'e  elbow  is  not  simply  a  reduction  that  restores  continuity 
of  the  fragments,  but  one  that  restores  functional  activity  of  the 
joint.  In-lthe  fracture  of  a  long  bone  a  slight  discrepancy  of  the 
fragments  is  compatible  with  perfect  functional  result.  But  in  frac- 
ture of  the  elbow  even  slight  abnormal  prominence  in  the  interior  of 
the  joint  will  be  an  obstacle  to  normal  joint  movements,  and  may 
be  the  cause  of  permanent  disability.  It  is  obvious  that  reduction 
here  is  something  more  than  the  reposition  of  fragments ;  it  implies 
a  coaptation  so  accurate  and  a  retention  so  complete  that  the  result- 
ing joint  surfaces  will  permit  of  normal  joint  movements. 

If  the  fragments  be  accurately  reduced  and  held  in  this  position, 
the  questions  of  duration  of  immobilization  and  the  special  position 
in  which  the  limb  should  be  placed  are  secondary  considerations. 
The  fundamental  fact  must  be  appreciated  that  it  is  not  the 
duration  of  the  immobilization  that  produces  ankylosis,  it  is  faulty 
reduction  causing  periosteal  proliferation  that  locks  the  joint ;  and, 


FEACTURES    AT    THE    ELBOW  583 

further,  no  special  position  of  the  arm  will  obviate  the  disastrous 
results  of  an  incomplete  reduction. 

The  general  rule  to  be  followed  in  all  cases  of  fractured  dhow 
is — accurate  reduction  maintained  by  that  splint  and  that  position 
of  the  arm  which  is  best  suited  to  the  special  indications  of  the  indi- 
vidual case. 

It  is  futile  and  misleading  to  presume  to  indicate  precise  methods 
of  treatment  invariably  applicable  to  each  variety  of  fractured 
elbow.  Even  in  the  same  type  of  fracture  there  are  anatomical  dif- 
ferences which  must  be  appreciated.  Some  displacements  are  cor- 
rected by  traction,  others  by  direct  pressure  on  the  fragment.  Each 
fracture  is  a  special  problem,  with  its  individual  needs  and  its 
peculiar  indications.  While,  therefore,  no  precise  rules  can  be 
formulated,  certain  precepts  may  be  followed  which  will  be  a  safe 
guide  in  all  cases. 

First  Step :  Find  out  exactly  just  what  is  fractured  and  be  satis- 
fied with  nothing  but  anatomical  accuracy. 

A  clinical  examination  under  anesthesia  is  the  first  requisite; 
but  it  is  never  sufficient;  it  must  be  supplemented  by  an  X-ray 
examination.  Two  radiographs  should  be  made,  one  profile,  and 
one  surface  view.  The  radiographs  should  be  made  and  interpreted 
by  a  radiographer  of  experience.  The  X-ray  picture  without  proper 
interpretation  is  futile. 

Second  Step :  Reduce  the  fracture  by  such  maneuvers  as  are 
efficient  in  accurately  coapting  the  fragments  (flexion,  extension, 
traction,  direct  pressure,  etc.).  A  maneuver  is  selected  for  its  effir 
ciency  and  not  according  to  precedent.  Whatever  the  maneuvers, 
care  should  be  taken  to  avoid  any  rough  manipulation,  which  only 
exaggerates  periosteal  lesions,  and  consequent  impairment  of  func- 
tion. Firmness  and  gentleness  are  always  more  effective;  they  ac- 
complish more  and  damage  less. 

Third  Step:  Immobilize  permanently  only  when  certain  that  re- 
duction has  been  obtained,  and  that  the  position  of  the  arm  and  the 
splint  selected  are  adequate  to  maintain  reduction.  This  will  be 
evidenced  by  (a)  normal  conformation  of  the  parts ;  (b)  a  normal 
range  of  flexion  and  extension.  But  best  of  all  is  the  confirmation 


584  THE  ELBOW 

furnished  by  a  second  radiograph.  The  procedure  should  be  as 
follows : 

After  reduction  has  been  obtained,  and  the  arm  placed  in  that 
position  which  seemingly  is  most  efficient  in  maintaining  reduction, 
a  temporary  splint  should  be  applied  and  a  radiograph  taken;  if 
the  picture  confirms  the  accuracy  of  reduction  and  efficiency  of 
immobilization,  then  the  temporary  splint  should  be  made  perma- 
nent. And  no  permanent  immobilization  should  be  attempted  until 
satisfactory  evidence  has  been  obtained  that  the  reduction,  position 
of  arm,  and  splint  are  as  perfect  as  the  character  of  the  injury  per- 
mits. 

Lastly:  In  the  choice  of  splints  preference  should  always  be 
given  to  plaster  of  paris.  No  other  form  of  splint  can  be  molded 
so  accurately  or  held  so  securely — an  important  consideration  where 
the  child's  restlessness  predisposes  to  secondary  displacement. 

SPECIAL  INDICATIONS  IN  THE  TREATMENT  OF  FRACTURES  OF 
THE  ELBOW. — I.  Fractures  Without  Displacement. — These  frac- 
tures are  quite  rare.  The  prognosis  is  good  providing  the  proper 
method  of  treatment  is  pursued.  There  being  no  reduction  neces- 
sary and  the  function  of  the  joint  being  unimpaired  the  necessity 
of  careful  immobilization  is  not  always  appreciated.  To  put  such 
a  fracture  simply  in  a  sling  is  an  error,  and  to  begin  mobilization 
of  the  joint  too  early  is  fraught  with  grave  danger.  The  fracture 
should  be  immobilized  with  great  care,  and  early  movement  of  the 
joint  avoided  lest  exuberant  periosteal  proliferation  be  stimulated 
and  secondary  displacements  induced. 

A  well  fitting  plaster  splint  should  be  applied  and  the  arm 
immobilized  for  three  weeks. 

II.  Fractures  with  Displacement. — A.  Supracondylar  Fracture. 
— If  the  fracture  is  seen  a  few  hours  after  the  traumatism  the  swell- 
ing is  at  its  height  and  it  is  better  to  wait  two  or  three  days  until 
the  swelling  subsides  before  attempting  to  reduce  and  permanently 
immobilize.  In  the  meantime  place  the  arm  in  a  temporary  internal 
angular  splint  (Fig.  226). 

After  the  swelling  has  subsided  (at  end  of  48  to  72  hours) 
anesthetize  the  patient  (in  the  presence  of  an  X-ray  if  possible) 


585 


FIG.  226. — INTERNAL  ANGULAR  SPLINT  PADDED 
WITH  SHEET  WADDING  AND  FASTENED 
WITH  ADHESIVE  STRIPS.  (After  Cotton.) 


and  make  accurate  reduction 

by  such  manipulations  as  are 

most  efficient.   Usually  reduc- 
tion is  best  accomplished  by 

having     an     assistant    make 

countertraction  and  backward 

pressure     upon     the     upper 

fragment.     The  surgeon 

meanwhile  by  a  steady  pull 

downward  upon  the  forearm 

reduces  the  upward  displace- 
ment of  the  lower  fragment, 

and  then  by  a  movement  of 

forced  flexion  brings   the  fragment  forward   into  its  normal  rela- 
tion with  the  diaphysis. 

In  making  this  reduction  two  errors  should 
be  carefully  avoided: 

First:  In  the  movement  of  forced  flexion  of 
the  forearm  care  should  be  taken  not  to  over- 
reduce,  that  is,  transform  the  original  posterior 
displacement  into  an  anterior  displacement,  and 
thus  compromise  restoration  of  function. 

Second :  There  is  nearly  always  some  lateral 
displacement,  especially  some  inward  deviation, 
which  if  not  corrected  results  in  "gun-stock"  de- 
formity (loss  of  the  "carrying-angle").  (Fig. 
227.)  This  deviation,  while  not  interfering  with 
the  function  of  the  joint,  results  in  a  deformity 
sometimes  inconvenient. 

Reduction,  therefore,  to  be  complete  must  cor- 
rect not  only  the  backward  displacement  of  the 
fragment  but  its  lateral  deviation.     The  difficulty, 
FIG    227— "  GUN-     however,   ig   in   the   fact   that   the    movement   of 

STOCK"  DEFOB-      forced  flexion  which  brings  the  displaced  fragment 

MITY  CAUSED  BY 

OBLITERATION     forward  into  position  does  not  correct  the  lateral 

OF  THE  "CARRY-  ...  .  ,. 

ING  ANGLE."          deviation,  it  only  obscures  it.     Lateral  displace- 


586  THE  ELBOW 

ment  is  corrected  only  with  the  forearm  in  complete  extension. 
Hence,  when  making  the  first  movement — traction  downward  on 
the  extended  forearm — be  sure  that  any  lateral  deviation  is  cor- 
rected and  maintained  before  forcibly  flexing  the  forearm.  Repeat 
the  movements  of  reduction  as  often  as  necessary  to  be  assured  that 
the  reduction  is  complete. 

Retention. — After  reduction  nas  been  obtained  the  fragment 
must  be  permanently  held  in  position  by  some  retentive  splint. 
The  tendency  to  secondary  displacement  in  these  fractures  must  be 
prevented  not  only  by  a  well-fitting  splint,  but  by  that  special  posi- 
tion of  the  forearm  in  which  the  reduction  is  best  protected.  The 
best  position  is  the  position  which  holds  the  fragments  in  place. 
While  the  general  rule  holds  good,  viz. :  to  immobilize  in  that  posi- 
tion and  by  that  splint -which  maintains  the  best  reduction,  experi- 
ence has  shown  that  the  fragments  are  best  coapted  with  the  fore- 
arm flexed  either  at  -a  right  angle  or  an  acute  angle  (hyperflexion — 
the  "Jones  position").  Both  positions  should  be  tried;  select  the 
position  which  maintains  the  best  reduction,  put  on  a  temporary 
splint,  and  verify  the  selection  by  the  radiograph. 

In  right  angle  flexion  the  fragments  are  best  retained  by  the 
application  of  an  internal  angular  splint  molded  of  plaster  of  paris 
extending  from  the  line  of  the  axilla  to  the  wrist  (leaving  the 
fingers  of  the  child  at  liberty).  The  splint  is  padded  with  sheet 
wadding  and  crowded  well  into  the  bend  of  the  elbow  (Fig.  228). 
The  splint  is  held  in  position  by  adhesive  strips  around  the  arm 
and  wrist,  the  limb  enswathed  in  cotton,  and  a  bandage  applied 
from  the  wrist  to  the  upper  border  of  the  splint.  The  arm  must 
not  be  supported  by  a  sling  since  pressure  of  a  sling  has  a  tendency 
to  invite  displacement  of  the  fragments. 

In  acute  flexion  ("Jones  position")  the  fragment  is  reduced  and 
maintained  in  position  by  forced  flexion,  so  that  the  forearm  is  in 
contact  with  the  anterior  surface  of  the  arm.  The  coronoid  process 
in  front,  the  hook-like  process  of  the  olecranon  behind,  and  the 
strap-like  tendon  of  the  triceps,  all  these  elements  conspire  to  keep 
the  fragment  reduced  and  pressed  firmly  against  the  shaft  of  the 
humerus. 


FRACTURES   AT    THE    ELBOW 


587 


Method  of  Applying  the  Acutely  Flexed  Position. — The  degree 
of  flexion  possible  will  depend  upon  the  amount  of  swelling-  present. 
Place  a  piece  of  well-powdered  gauze  in  the  bend  of  the  elbow,  and 
with  the  forearm  acutely  flexed  retain  the  position  by  an  adhesive 
strip  three  inches  wide  passing  about  the  arm  arid  forearm.  (Fig. 
229.)  Place  a  gauze  compress  to  protect  the  skin  where  the  hand 
and  forearm  come  in  contact  with  the  chest,  and  support  the  arm 


FIG.  228. — APPLICATION  OF  THE  INTERNAL  ANGULAR  SPLINT  FOR  FRACTURE  OF  THE 

ELBOW. 

Note  in  the  first  position  that  the  splint  is  applied  to  the  arm,  and  the  forearm  flexed  up- 
on the  splint.  In  the  second  position  the  angle  of  the  splint  is  crowded  into  the 
bend  of  the  elbow  while  the  adhesive  straps  are  applied. 

by  a  plaster  bandage  enswathing  the  arm   and  chest,  leaving  the 
fingers  of  the  child  at  liberty. 

A  vigilant  supervision  should  be  kept  of  the  acutely  flexed  arm 
for  the  first  week.  Watch  the  radial  pulse— the  vessels  at  the  bend 
of  the  elbow  are  readily  compressed  by  acute  flexion,  especially  if 
swelling  be  present.  Adjust  the  amount  of  flexion  according  to  the 
amount  of  swelling;  the  degree  of  the  patient's  comfort  will  indicate 
the  need  for  readjustment  of  the  dressings. 


588 

Duration  of  Immobilization. — As  a  rule  the  fracture  should  be 
immobilized  for  three  weeks.  It  is  well  at  the  end  of  the  first  weeki 
to  remove  the  dressings  and  readjust  them  since  there  is  a  tendency 
for  them  to  become  loose  as  the  swelling  subsides.  It  is  a  wise  pre- 
caution at  this  time  to  verify  the  efficiency  of  the  position  again  by 
a  radiograph. 

At  the  end  of  the  third  week  the  dressing  should  be  removed 
and  the  efforts  of  the  surgeon  directed  toward  the  establishment  of 


FIG.  229. — NOTE  IN  FIRST  POSITION  THE  ARM  is  HELD  IN  A  POSITION  OF  FORCED  FLEXION 
BY  ADHESIVE  STRAP.  IN  SECOND  POSITION  THE  DRESSING  IB  COMPLETED  BY  A 
PLASTER  BANDAGE  ENSWATHING  THE  ARM  AND  CHEST. 

normal  joint  movement.  These  efforts,  however,  should  not  be  in 
the  line  of  passive  movements  which  force  flexion  and  extension; 
nothing  is  gained  by  this  practice.  Forced  movements  are  not  only 
unnecessary,  they  are  harmful.,  and  often  cause  the  ankylosis  they 
seek  to  avert.  The  efforts  of  the  surgeon  should  be  directed  toward 
encouraging  the  child  to  make  the  movements  himself.  Spontaneous 
movements  are  slower,  but  they  are  much  surer,  and  in  the  end  will 
achieve  the  best  results.  Be  patient  and  remember  that  restoration 


FKACTUKES    AT    THE    ELBOW  589 

of  joint  function  is  slow.     Be  satisfied  if  normal  joint  movement  is 
reestablished  in  three  or  four  months. 

B.  Separation  of  the  Lower  Epiphysis  of  the  Humcrus. — The 
treatment  is  the  same  as  in  supracondylar  fracture  of  the  humerus 
(see  p.  584). 

C.  Fracture  of  the  External  Condyle. — Reduction  of  this  frac- 
ture is  not  always  easy,  since  the  fragment  is  small  and  obscured 
by  swelling  of  the  overlying  tissues.     It  will  be  found  serviceable 
here   to   combine   traction  with   direct   pressure   on    the    fragment. 
With  the  patient  anesthetized  have  an  assistant  make  traction  on  the 
forearm  and  apply  direct  pressure  to  the  displaced  fragment  until 
reduction  is  obtained.     Place  the  forearm   in  that  position  which 
best  holds  the  fragment  in  place,  put  on  a  temporary  splint,  and 
verify  the  results  by  a  radiograph.     The  final  position  may  be  one 
of  complete  extension,  right  angle  flexion,  or  acute  flexion.      The 
surgeon  need  not  hesitate  to  adopt  the  position  which  maintains  re- 
duction, even  though  this  be  complete  extension,  since  it  is  some- 
times necessary  to  resort  to  this  position  to  avoid  an  ultimate  cubitus 
valgus  or  varus. 

D.  Fracture  of  the  Internal  Epicondyle. — It  should  be  remem- 
bered that  the  attached  muscles  tend  to  draw  the  fragment  forward 
and  downward,  hence  the  elbow  should  be  immobilized  in  the  acutely 
flexed  position   (see  p.   587)   to  relax  the  muscles  that  arise  from 
the  epitrochlear.     Even  when  the  fragment  is  not  reduced  the  de- 
formity is  slight  and  in  no  way  compromises  function.     Consolida- 
tion is  sufficiently  advanced  at  the  end  of  ten  days  to  place  the  arm 
in  a  sling.     The  arm  may  be  used  at  the  end  of  three  weeks. 

OPERATIVE  TREATMENT  ix  FRACTURES  AT  THE  ELBOW. — It  is 
evident  that  even  under  the  most  favorable  circumstances  there  are 
a  few  fractures  at  the  elbow  which  cannot  be  satisfactorily 
reduced.  To  immobilize  an  unreduced  fracture  is  to  invite  at 
least  an  imperfect  functional  result,  sometimes  a  disastrous  re- 
sult. There  are  certain  fractures  which  cannot  be  reduced  by 
the  ordinary  means  of  traction  and  direct  pressure  because  of  an 
impaction  or  interposition  of  fragments.  In  such  cases  operation 
is  indicated,  either  to  restore  the  fragment  to  its  normal  position, 


590  THE  FOKEAKM  AND  HAND 

or  failing  in  this  to  remove  it.  Intervention  in  these  cases  should 
be  done  early,  not  later  than  the  third  or  fourth  day ;  where  opera- 
tion is  delayed  until  the  period  of  full  periosteal  activity  the  addi- 
tional irritation  favors  exuberant  periosteal  proliferation  and  subse- 
quent functional  impairment. 

In  cases  of  vicious  union  operation  is  indicated  only  when  the 
movements  of  the  joint  are  sufficiently  limited  to  warrant  interven- 
tion. It  is  obvious  that  these  cases  may  entail  the  removal  of  a 
bony  prominence;  or,  when  complete  ankylosis  exists,  a  total  resec- 
tion. It  is  important  to  remember  that  operation  in  these  cases 
should  never  be  done  early  in  the  active  stage  of  periosteal  pro- 
liferation. Wait  until  six  months  after  the  injury. 

In  nerve  injuries  the  irritation  is  usually  due  either  to  exuberant 
callus  or  compression  by  a  displaced  fragment.  In  case  of  ex- 
uberant callus  the  chances  are  that  the  symptoms  will  disappear  as 
the  callus  is  absorbed.  When  the  nerve  is  compressed  by  a  frag- 
ment of  bone  it  is  necessary  to  free  the  nerve,  otherwise  the  paraly- 
sis will  become  permanent. 


CHAPTER  LXXII 

THE    FOKEAKM    AND    HAND 

GREEN-STICK  FRACTURE  OF  THE  FOREARM 

Incomplete  or  green-stick  fracture  of  the  bones  of  the  forearm 
occurs  in  children  as  a  result  of  a  fall  upon  the  outstretched  hand 
or  a  blow  upon  the  forearm.  The  deformity  is  characteristic ;  there 
is  an  exaggeration  of  the  normal  curve — a  bowing  backward  at  the 
seat  of  fracture  (Fig.  230).  Pain  and  tenderness  are  present,  but 
crepitus  is  absent ;  hence  this  injury  is  often  diagnosed  as  a  "sprained 
arm."  A  radiograph  will  assist  in  confirming  the  diagnosis. 

Treatment. — The  reduction  should  be  made  under  anesthesia, 
and  when  possible  confirmed  by  a  radiograph.  Reduction  should  be 
made  by  traction  and  careful  pressure  upon  the  bones  at  the  seat 


VOLKMANN'S   ISCHEMIC    CONTRACTUEE 


591 


of  fracture.  It  should  be  re- 
membered that  reduction  must 
be  done  cautiously,  and  if  pos- 
sible  the  bones  should  ba 
molded  back  to  their  original 
form  without  completing  the 
fracture. 

O  v  e  r-correction,  however, 
may  result  in  displacement 
which  impairs  the  special  func- 
tion of  rotation  of  the  forearm 
(pronation  and  supination). 
While  making  the  reduction 
the  hand  should  be  supinated, 
since  in  this  position  the  bones 
are  parallel  and  separated  by 
the  greatest  interval. 

The  forearm  should  be  im- 
mobilized in  a  position  of  FIG.  230. — GREEN-STICK  FRACTURE  OF  THE 

BONES  OF  THE  FOREARM. 

supination   with    the   elbow    at 

a  right  angle.  Molded  plaster-of-paris  splints  (internal  and  external 
angular)  extending  above  the  elbow,  and  held  in  position  by  adhesive 
strips,  are  especially  suitable  in  children.  Traction  on  the  forearm 
should  be  made  while  the  plaster  hardens.  (Fig.  231.) 


VOLKMANN'S  ISCHE- 
MIC CONTRACTURE 

Volkmann's  ischemic 
contracture  is  a  contrac- 
tion of  the  muscles  of  the 
forearm  from  muscle 
ischemia  due  to  the  appli- 
cation of  too  tight  ban- 
dages. The  flexed  posi- 


FIG.  231. — FRACTURE  OF  THE  FOREARM  IMMOBIL- 
IZED   IN    A    POSITION    OF    SUPINATION. 


592  THE  FOREARM  AND  HAND 

tion  of  the  forearm  with  the  end  of  a  splint  jammed  against  the  bend 
of  the  elbow  is  a  prevalent  cause.  The  diminution  of  the  blood 
supply  causes  muscular  atrophy,  increase  and  contraction  of  con- 
nective'tissue,  and  shortening  of  the  muscles.  As  a  result  of  this 
contracture  the  hand  assumes  a  typical  position,  the  wrist  and  fingers 
being  permanently  flexed. 

This  condition  may  be  improved  by  forcible  stretching,  massage, 
active  and  passive  movements.  In  exceptional  cases  lengthening  of 
all  the  flexor  tendons  has  given  excellent  results.  (J.  K.  Murphy.) 


SUBLUXATION  OF  THE  HEAD  OF  THE  RADIUS 

Subluxation  of  the  head  of  the  radius  is  frequently  observed  in 
children  under  four  years  of  age.  It  is  caused  by  sudden  traction 
on  the  arm  at  the  hand  such  as  is  produced  by  a  sudden  pull  on  the 
arm  in  assisting  a  child  up  a  step,  or  supporting  it  when  it  stumbles. 
(Two  cases  in  drawing  the  arm  through  the  sleeve  of  the  dress. — 
Stimson.) 

The  lesion  is  produced  by  traction  on  the  extended  elbow,  caus- 
ing an  escape  of  the  front  portion  of  the  head  of  the  radius  below 
the  orbicular  ligament.  (Duverney.) 

Symptoms. — The  attitude  is  typical — slight  flexion  at  the  elbow 
with  the  hand  held  in  complete  pronation.  The  child  refuses  to  use 
the  arm,  and  cries  out  when  the  surgeon  attempts  to  examine  it. 
There  is  no  noticeable  swelling  or  deformity;  the  elbow  can  be 
moved  in  every  direction  except  supination :  supination  is  distinctly 
limited.  This  symptom  is  pathognomonic. 

The  typical  history  and  characteristic  attitude  are  sufficient  to 
establish  a  diagnosis. 

Treatment. — The  reduction  is  made  without  difficulty  by  traction 
on  the  forearm  with  direct  pressure  on  the  head  of  the  radius.  The 
reduction  is  complete  when  all  motions  at  the  elbow  are  normal.  It 
is  usually  sufficient  to  support  the  arm  in  right  angle  flexion  with 
a  sling  for  forty-eight  hours,  after  which  the  child  may  be  permitted 
to  use  the  arm. 


FRACTURE    OF    THE    LOWEE    END    OF    RADIUS      593 
MADELUNG'S  DEFORMITY 

(Spontaneous  Subluxation  of  the  Wrist) 

This  deformity  (Fig.  232)  consists  of  a  forward  subluxation  of 
the  wrist  with  a  dorsal  prominence  of  the  head  of  the  ulna.  The 
condition  is  rare  and  found 
mostly  in  girls.  The  affec- 
tion is  essentially  a  develop- 
mental defect  of  the  lower 
epiphysis  of  the  radius, 
the  articular  surface  of 
which  no  longer  maintains  a 
right  angle  with  the  plane  of 
the  forearm,  but  bends  for- 
ward toward  the  palmar  sur- 
face, carrying  with  it  the  at- 
tached carpus,  thus  produc- 
ing displacement  of  the  wrist, 
and,  as  a  sequence,  accentu- 
ating the  prominence  of  the 
head  of  the  ulna.  It  begins  after  the  twelfth  year  and  usually  takes 
some  years  to  fully  develop.  It  is  found  both  single  and  double. 
It  is  accompanied  by  pain  and  disturbance  of  function,  especially 
rotation  and  hyperextension. 

Treatment. — Reduction  is  impossible.  Little  can  be  accomplished 
by  surgical  or  orthopedic  means.  In  severe  cases  osteotomy  of  the 
radius  may  be  considered  after  the  disease  has  run  its  course. 


FIG.  232. — MADELUNG'S  DEFORMITY.  (Stetten's 
Case.) 


FRACTURE  OF  THE  LOWER  END  OF  THE  RADIUS 

Fracture  of  the  lower  end  of  the  radius,  while  frequent  in 
adults,  rarely  occurs  in  children.  The  force  which  produces  a  frac- 
ture of  the  lower  end  of  the  radius  in  adults  in  young  children 
results  in  a  green-stick  fracture  of  both  bones  of  the  forearm. 


594  THE  FOEEARM  AND  HAND 

In  older  children,  however,  we  often  find  a  fracture  of  the  lower 
end  of  the  radius  near  the  epiphyseal  line — pure  epiphyseal  separa- 
tion is  very  rare  and  only  in  young  children.  The  deformity  re- 
sembles that  of  Colles'  fracture  ("silver-fork"  deformity),  but  is 
less  extreme.  The  fragment  is  displaced  backward,  causing  a  promi- 
nence at  the  back  of  the  wrist,  which  might  suggest  a  dislocation. 
Diagnosis  should  be  confirmed  by  a  radiogaph. 

Treatment. — Accurate  reduction  is  essential.  Imperfect  reduc- 
tion may  seriously  interfere  with  the  growth  of  the  bone.  Immobil- 
ize with  plaster  splint. 


TUBERCULOSIS  OF  THE  WRIST 

Tuberculosis  of  the  wrist  is  rare.  Beginning  in  a  single  bone 
it  spreads  throughout  the  carpus.  Its  existence  is  facilitated  by 
the  numerous  synovial  cavities  which  surround  the  carpal  bones, 
and  the  proximity  of  the  tendon  sheaths  renders  them  liable  to 
invasion. 

It  will  be  noted  that  the  palmar  side  of  the  wrist  is  protected 
by  a  mass  of  tendons,  the  dorsal  surface  being  more  superficial ; 
hence  the  objective  symptoms  are  found  on  the  dorsal  surface  of 
the  wrist. 

Symptoms  are  similar  to  those  of  tubercular  joints  elsewhere — 
pain,  swelling,  fixation  in  vicious  attitude,  loss  of  function,  and 
muscular  atrophy.  The  later  stages  of  the  disease  are  marked  by 
fistulse,  which  open  on  the  back  of  the  wrist.  It  will  be  recalled 
that  the  radius  is  the  handle  of  the  hand  and  that  it  is  the  radius 
which  enters  into  the  formation  of  the  wrist  joint,  not  the 
ulna,  hence  articular  activity  is  in  the  radial  side  of  the  wrist 
and  it  is  on  the  radial  side  that  the  tubercular  process  first  appears. 
The  swelling  causes  the  bony  prominences  to  disappear  and  the  fur- 
rows between  the  hand  and  the  arm  are  lost.  Furthermore,  the  de- 
formity is  increased  by  the  vicious  attitude  shown  in  extension  of 
the  fingers  and  flexion  and  pronation  of  the  hand.  Movements  of 
flexion  and  extension  are  gradually  diminished  and  finally  disap- 


TUBERCULOSIS  OF  THE  PHALANGES      595 

pear  as  the  tendon  sheaths  are  invaded.  Finally,  the  hand  becomes 
an  inert  mass  deprived  of  all  function.  Any  difficulties  in  diag- 
nosis will  be  cleared  away  by  the  X-ray. 

Prognosis. — The  anatomical  conditions  favor  extension  of  the 
process,  and  cure  of  the  disease  is  always  attended  with  great  loss 
of  function. 

Treatment. — The  GENERAL,  TREATMENT  is  that  of  surgical  tuber- 
culosis (see  Joint  Tuberculosis,  p.  20T). 

LOCALLY  the  wrist  should  be  immobilized  in  plaster  (the  hand 
in  extension,  midway  between  pronation  and  supination)  as  soon 
as  the  diagnosis  is  made.  The  cast  should  extend  to  the  upper  third 
of  the  forearm,  the  fingers  being  left  free  so  that  they  may  be  exer- 
cised by  active  and  passive  movements.  The  cast  should  not  be  dis- 
pensed with  until  all  pain  and  inflammatory  reaction  have  disap- 
peared for  three  months.  The  blood  supply  to  the  diseased  part 
should  be  increased  by  artificial  chronic  congestion  according  to  the 
method  of  Bier. 

Abscesses  should  be  aspirated  and  their  contents  removed  by 
suction,  and  five  per  cent,  emulsion  of  iodoform  and  glycerin  or  a 
two  per  cent,  emulsion  of  formalin  and  glycerin  injected.  Other- 
wise the  treatment  is  conservative,  even  in  advanced  cases,  for,  as 
Kirmisson  observes,  "in  dealing  with  bony  and  articular  tubercle 
in  children  there  are  no  limits  to  the  possibilities  of  conservative 
treatment." 

Finally,  the  outlook  in  resection  of  the  wrist  is  not  encouraging. 
The  numerous  tendons  which  cover  both  the  anterior  and  posterior 
surfaces  of  the  articulation :  the  invasion  of  synovial  pockets,  the 
difficulty  of  removing  all  the  diseased  tissue  without  sacrificing 
important  organs,  the  dissemination  of  the  disease  in  the  efforts  to 
remove  it  render  resection  of  the  wrist  a  procedure  of  more  doubt- 
ful value  than  that  of  the  shoulder  or  elbow. 

TUBERCULOSIS   OF   THE   PHALANGES 

Tuberculosis  of  the  phalanges  is  quite  frequent  in  childhood, 
especially  during  the  second  and  third  years,  and  presents  a  char- 


596 


THE  FOREARM  AXD  HAND 


acteristic  clinical  picture  which  appears  under  the  form  of  spina 
ventosa  (Fig.  233). 

The  disease  attacks  the  small  pipe  bones  of  the  hand  and  foot, 
the  tubercle  localizing  primarily  either  in  the  periosteum  or  the 
central  spongy  tissue.  Here  we  note  the  effect  of  the  invading 
tubercle  and  the  irritative  hyperplasia  of  surrounding  tissue  in  the 
characteristic  swelling  of  the  bone,  which  presents  a  spindle '-sh  aped 
enlargement. 

Later  the  skin  ulcerates,  the  bone  becomes  perforated,  a  fistula 
is  formed,  and  the  tendon  sheaths  become  infected.  As  a  rule  this 

form  of  tuberculosis  is  exclu- 
sively diaphyseal,  the  articula- 
tions being  nearly  always  exempt. 
Spina  ventosa  is  relatively 
benign  and  prior  to  ulceration 
spontaneous  cure  by  resolution  is 
possible.  Even  after  fistuliza- 
tion  small  sequestra  may  be  ex- 
pelled, the  sinus  close,  and  a  good 
result  be  obtained,  though  often 
at  the  cost  of  more  or  less  de- 
formity. 

Treatment. — The  general  treat- 
ment of  bone  tuberculosis  (see 
p.  207)  ;  Locally,  avoid  much  interference  and  remember  the  fre- 
quency of  spontaneous  cure. 

Immobilize  the  part,  apply  Bier's  hyperemia  treatment,  relieve 
abscess  by  aspiration  and  suction,  remove  sequestra,  inject  the  fistu- 
lous  tract  with  five  per  cent,  iodoform  and  glycerin  emulsion. 

Avoid  the  knife  since  spontaneous  cure  gives  better  functional 
results  than  operative  cure. 

In  cases  of  complete  destruction  of  the  bone  the  function  of  the 
finger  may  be  preserved  by  transplanting  between  the  remaining 
epiphyseal  surfaces  a  spicula  of  bone  taken  from  the  tibia,  or  one  may 
resort  to  Bardenheuer's  method  of  replacing  the  diseased  phalanx  by 
taking  a  bony  flap  from  the  adjoining  phalanx  and  turning  it  around 


FIG.  233.— SPINA  VENTOSA. 


CONGENITAL   DEVIATIONS    OF    THE    HAND 


597 


its  articular  surface  so  that  the  new  fragment  of  bone  bridges  the 

gap- 
Amputation  of  a  tuberculous  finger  should  only  be  resorted  to  as 
a  last  extremity  when  there  is  complete  destruction,   infection  of 
neighboring  structures,  or  painful  deformity. 


CONGENITAL   DEVIATIONS   OF   THE   HAND 


Varieties. — Permanent  deviations  of  the  hand  or  the  wrist  are 
associated  with  absence  as  well  as  complete  or  partial  defects  of  the 
bones  of  the  forearm. 

Clubbed  hand  is  that  condition  in  which  the  hand  does  not  form 
a  normal  angle  with  the  forearm.     Only  in  rare  cases  is  there  a 
clubbed    hand    without    defective 
formation  of  the  skeleton  of  the 
forearm.     (Fig.  234.) 

Usually  it  is  associated  with 
absence  of  radius  or  ulna,  com- 
monly the  radius:  The  hand  is 
then  inclined  toward  the  radial 
side  and  forms  a  right  angle  with 
the  ulna.  The  end  of  the  ulna  is 
easily  palpated  beneath  the  skin. 
With  this  deformity  the  thumb 
and  its  metacarpal  bone  are  usu- 
ally missing. 

The  ulna  is  rarely  absent: 
Here  the  hand  is  deviated  toward 
the  ulnar  side,  but  movement  at 
the  wrist  is  free.  The  elbow  on 
the  contrary  is  often  completely 
ankylosed. 

Etiology. The  etiology  of       FIG.  234.— CLUBBED  HAND  WITH  MAL- 

,i  IP  .        ,.  n     •          ,  i  FORMATION    OF    THE     BONES    OF  THE 

these  delects  IS  found  in  the  proc-  FOREARM.  (Goodrich's  case.) 


598  THE  FOREAEM  AND  HAND 

ess  of  development,  but  the  explanations  of  it  are  entirely  specula- 
tive. 

Treatment  consists  in  the  use  of  various  orthopedic  apparatus 
appropriate  to  the  condition. 

By  operation  we  may  lengthen  or  shorten  the  tendons  according 
as  the  deformity  demands. 

In  absence  of  the  radius  Bardenheuer  has  ingeniously  split  the 
ulna  and  inserted  the  carpus  into  the  fork  with  good  results. 


INJURIES   OF   THE  HAND   IN   CHILDHOOD 

The  accidents  of  childhood  are  largely  those  which  occur  to  the 
child  in  the  process  of  becoming  acquainted  with  his  environment. 
Incised  and  lacerated  wounds  of  the  hand  from  implements  used 
in  the  family  life,  burns  and  scalds  from  playing  with  matches  or 
proximity  to  the  stove,  injuries  to  the  bones  by  falling  down  stairs, 
and  the  countless  injuries  which  are  the  result  of  the  games  and 
sports  of  childhood. 

Incisee},,  and  lacerated  wounds  should  be  treated  according  to  the 
accepted  rules  of  aseptic  and  antiseptic  surgery,  with  the  following 
precautions : 

Avoid  the  use  of  those  disinfecting  agents  to  which  the  child's 
tissues  are  very  sensitive,  especially  avoid  carbolic  acid.  This  anti- 
septic agent  should  find  no  place  in  the  surgery  of  childhood.  The 
danger  of  carbolic  gangrene  when  carbolic  solutions  are  applied  to 
the  digits  must  not  be  forgotten. 

Do  not  attempt  to  disinfect  wounds  by  scrubbing  with  green 
soap.  Such  methods  do  more  harm  to  the  tissues  than  to  the  bac- 
teria which  lie  hidden  in  the  lymph  spaces. 

After  splinters  and  debris  have  been  removed  the  wounded  1  is- 
sues should  be  painted  with  half-strength  iodin  solution.  It  is  the 
most  satisfactory  antiseptic  for  wounds  that  we  possess. 

When  the  wound  has  come  in  contact  with  soil  or  gunpowder 
^firecracker  wounds)  the  patient  should  be  guarded  against  tetanus 
by  prophylactic  injections  of  antitetanic  serum.  Such  injections 


INJUEIES    OF    THE    HAND    IN    CHILDHOOD          599 

can   do  no  harm — their   omission   and    subsequent   development   of 
tetanus  should  rightfully  subject  the  physician  to  severe  censure. 

Treatment. — Wounds  of  the  hand  are  among  the  most  important 
lesions  which  claim  the  attention  of  the  surgeon.  The  hand  is 
naturally  predisposed  to  wounds  of  all  kinds,  specially  those  result- 
ing from  machinery  accidents,  and  the  explosion  of  fire-arms,  where 
the  resultant  condition  is  not  merely  a  wound  but  a  multiplicity  of 
wounds,  involving  to  a  greater  or  less  extent  vessels,  nerves,  tendons, 
muscles,  and  bone.  In  the  presence  of  such  injuries  it  is  impos- 
sible to  be  guided  by  hard  and  fast  rules  of  procedure — only  the 
general  principles  of  treatment  can  be  suggested.  Experience  and 
judgment  must  modify  them  to  suit  the  individual  case.  It  is 
urged  that  these  injuries  be  approached  in  a  spirit  of  conservatism 
with  the  determination  to  sacrifice  nothing  that  can  be  saved.  The 
inestimable  value  of  a  hand,  even  a  partial  hand,  is  the  strongest 
appeal  to  conservative  surgery.  Primary  amputations  of  the  hand 
should  be  classed  among  the  rarest  operations  in  the  domain  of 
surgery.  Nature  is  a  better  adjunct  than  the  knife  in  the  treatment 
of  these  conditions.  See  what  the  recuperative  forces  of  nature  will 
do  to  preserve  and  restore  the  wounded  parts.  Remember  that  the 
thumb  opposes  all  the  other  fingers,  hence  its  value  in  the  role  of 
prehension  is  vital.  //  the  thumb  be  removed  the  hand  is  reduced 
to  a  mere  hook.  A  single  finger  and  a  thumb  are  worth  more  than 
any  artificial  substitute. 

IMMEDIATE  TREATMENT. — After  explaining  the  gravity  of  the 
injury  and  obtaining  permission  to  do  whatever  is  necessary, 
anesthetize  the  patient.  Do  not  cleanse  the  wound  by  scrubbing 
with  green  soap — simply  saturate  the  wound  with  iodin  solution — 
half  strength ;  then  remove  with  thumb  forceps  the  debris,  splinters, 
and  loose  bone.  Ligate  all  bleeding  vessels,  then  study  the  anatomy 
of  the  wound.  What  tendons  and  nerves  are  involved  ?  What  dis- 
position of  the  parts  will  give  the  most  useful  hand  ?  Surgery 
should  be  constructive  as  well  as  conservative.  Make  an  immediate 
suture  of  the  severed  tendons  and  nerves.  Don't  do  too  much  cut- 
ting; cut  nothing  away  that  can  be  saved;  leave  too  much,  rather  than 
too  little;  arrive  at  no  hasty  conclusions  in  reference  to  amputation ; 


600  THE  FOREARM  AND  HAND 

irhcii  in  doubt  don't  amputate;  see  what  nature  will  do  first,  let 
amputation  be  a  secondary  consideration.  It  is  wonderful  how 
youthful  tissues  recuperate  under  conservative  treatment  and  useful 
function  is  restored.  Do  not  attempt  any  extensive  primary  plastics, 
because  of  the  dangers  of  infection.  After  attention  to  vessels, 
tendons,  and  nerves,  again  soak  the  wound  with  iodin — half 
strength — and  make  such  closure  of  the  wound  as  is  expedient  with 
safety,  but  don't  make  the  mistake  of  closing  the  wound  too  tightly, 
be  sure  and  leave  ample  room  for  drainage — these  wounds  poten- 
tially are  infected  wounds — closing  them  invites  disaster.  In  ex- 
tensive lacerated  wounds  of  the  hand  the  authors  regard  the  con- 
tinuous hand  bath  of  saline  solution  at  a  temperature  of  110°  as 
the  most  effective  after-treatment.  The  continuous  heat  and  ad- 
mirable drainage  which  the  continuous  bath  affords  make  it  an 
ideal  therapeutic  measure  for  the  preservation  and  restoration  of 
lacerated  tissues. 

After  all  dangers  of  infection  have  passed  the  efforts  of  the  sur- 
geon should  be  directed  toward  the  restoration  of  the  largest  degree 
of  function. 

Where  amputation  is  imperative  no  formal  method  must  be  con- 
sidered. The  extent  of  the  injury  determines  the  choice  of  method. 
Take  the  flap  whenever  you  can  find  it  with  the  least  possible  short- 
ening of  the  hand.  The  surgeon  will  select  that  method  which  sacri- 
fices the  least  amount  of  tissue. 

If  the  above  suggestions  are  observed  it  will  be  found  that  nature 
works  some  agreeable  surprises  even  in  injuries  that  are  seemingly 
irreparable. 

.MALFORMATION   OF   THE    FINGERS 

The  different  disturbances  of  development  result  in  curious 
anomalies  of  the  fingers,  such  as  polydactyly  (redundant  number  of 
fingers),  ectrodadyly  (insufficient  number  of  fingers),  and  syndac- 
tyly  (a  fusing  of  the  fingers). 

Polydactyly  is  the  most  frequent  malformation  and  calls  for 
surgical  intervention,  since  the  removal  of  these  unsightly  super- 


MALFORMATION    OF    THE    FIXGERS 


601 


fluous  fingers  is  desirable,  because  they  are  rarely  of  any  functional 
value. 

The  operative  removal  should  be  done  according  to  cosmetic 
principles,  and  no  operation 
should  be  done  if  there  is  any 
doubt  as  to  the  metacarpal  con- 
nections until  this  important 
point  is  demonstrated  by  the 
X-ray.  A  radiograph  shows  which 
of  the  fingers  is  superfluous. 

Syndactyly  (Fig. -235)  is  an 
urgent  indication  for  surgical 
intervention.  Here  the  condition 
demands  not  merely  a  cosmetic 
consideration  but  the  connected 
fingers  are  retarded  in  their 
growth. 

The  tissue  connecting  the  fingers  varies  from   a   thin  web   of 
skin  to  a  broad  bony  fusion  between  the  phalanges.     In  the  most 


FIG.  235. — SYNDACTYLY — WEBBED 
FINGERS. 


FIG.  236. — DIDOT'S  OPERATION  FOR  WEBBED  FINGERS. 

severe  cases  the  skin  passes  over  the  fingers  without  any  interdigital 
furrows  and  the  fingernails  are  then  unseparated. 

TREATMENT. — Permanent    separation    of    the    adherent    parts. 


LelZ   01-    OSTLOt- 
£   k.  SUKl: 


602 


The  greatest  difficulty  in  this  operation  lies  in  covering  in  the 
separated  surfaces  with  skin.  Unless  this  is  done  with  some  care 
the  parts  grow  together  again.  Hence  any  operation  to  be  success- 
ful must  contemplate  the  use  of  plastic  skin  flaps. 

The  deformity  should  be  corrected  by  a  plastic  operation  in  early 
childhood — the  second  or  third  year. 

Didot's  Operation  (Fig.  236). — "Two  narrow  longitudinal  flaps 
are  dissected  up  as  thick  as  possible  from  the  palmar  and  dorsal 
aspects  of  the  affected  fingers,  and  each  flap  is  folded  around  to 
cover  in  the  raw  surface  of  the  finger  to  which  it  is  attached."  The 
flaps  are  secured  by  interrupted  horse-hair  sutures.  (Jacobson.) 


£  U 


FIG.  237. — AGNEW'S  OPERATION  FOB  WEBBED  FINGERS. 

This  operation  is  ingenious  but  not  always  satisfactory  in  chil- 
dren, since  the  necessary  dissection  is  liable  to  injure  the  digital 
vessels  and  nerves.  A  simple  and  more  satisfactory  procedure  is — 

Agnew's  Operation  (Fig.  237). — A  triangular  flap  is  raised  from 
the  dorsal  surface  of  the  web  with  the  base  at  the  root  of  the  fingers. 
The  remainder  of  the  web  is  divided  and  the  flap  carried  through 
the  cleft  at  the  base  of  the  fingers  and  sutured  in  position.  The 
fingers  should  be  separated  and  immobilized  until  healing  is  com- 
plete. 

Ectrodactyly. — In  this  deformity  any  or  all  of  the  fingers  may  be 
absent.  It  is  often  associated  with  other  deformities  of  the  fingers, 
such  as  abnormal  development  of  individual  digits,  fusion  of  some 

jfjH 


MALFORMATION    OF    THE    FINGERS  003 

of  the  fingers,  absence  of  the  middle  finger  with  its  metacarpal,  pro- 
ducing "forked  hand." 

It  is  obvious  that  operative  interference  is  indicated  according 
to  requirements.  There  are  other  deformities  observed,  especially 
in  the  thumb.  Among  these  may  be  noted  "bifid  thumb"— &  double 
thumb,  each  with  its  own  metacarpal  bone  and  tendons.  It  is  obvious 
that  "bifid  thumb"  should  be  conserved  and  the  defect  modified  by  a 
plastic  operation. 

Occasionally  we  find  a  thumb  with  three  phalanges,  often  asso- 
ciated with  "bifid  thumb." 

Clubbed  Thumb. — This  malformation  is  sometimes  noted,  and 
consists  of  a  lateral  deviation  in  the  axis  of  the  thumb — the  second 
phalanx  forms  a  right  angle  with  the  first.  The  indications  are  to 
restore  the  thumb  to  its  normal  axis  by  division  of  the  fibrous  reten- 
tion bands  and  to  maintain  the  thumb  in  normal  position  by  a  splint 
that  corrects  the  deformity. 


SECTION  XIV 

THE    LOWER    EXTREMITY 

CHAPTEK  LXXIII 

CONGENITAL    DISLOCATION    OF    THE    HIP 

While  this  is  the  most  frequent  of  congenital  dislocations,  it  is 
not  a  common  affection.  It  occurs  more  frequently  in  girls  than  in 
boys  and  is  usually  unilateral. 

Etiology  and  Pathology. — A  number  of  causes  have  been  ad- 
vanced to  explain  this  condition,  but  the  theory  of  congenital  mal- 
formation— arrested  development,  resulting  in  an  unusually  small 
head  of  the  femur  and  a  shallow  acetabulum — rationally  accounts  for 
the  phenomena.  There  are  three  significant  facts  which  shed  some 
light  on  the  etiology  of  this  affection : 

First:  The  hereditary  factor.  It  appears  in  certain  families 
and  is  often  associated  with  other  defects. 

Second:  It  is  more  frequent  in  females  than  males   (7-1). 

Third:  It  is  more  frequent  in  the  higher  races  (5  to  10  times 
rarer  in  the  black  and  yellow  races. — Spitzy). 

These  facts  suggest  that  in  the  evolution  of  a  biped  certain 
structural  weaknesses  resulted  not  present  in  the  quadruped.  This  is 
notably  true  of  the  hip- joint — a  joint  not  as  well  adapted  for  the 
erect  posture  of  man  as  it  is  for  the  bent  posture  of  the  quadruped. 

Furthermore,  the  female  pelvis  has  broadened  out  to  adapt  itself 
to  the  larger  brain  and  consequent  larger  size  of  the  fetal  head.  As 
the  pelvis  broadens  the  acetabulum  becomes  shallow — hence  the 
greater  frequency  of  congenital  dislocation  in  the  female. 

A  clear  understanding  of  the  anatomical  defects  present  in  this 
affection  is  essential  to  appreciate  its  symptomatology  and  treatment. 

604 


ETIOLOGY    AND    PATHOLOGY  605 

Let  it  be  understood  that  in  congenital  dislocation  we  are  not 
dealing  with  a  ruptured  capsular  ligament  through  which  the 
femoral  head  has  torn  its  way.  We  are  dealing  with  a  displace- 
ment of  the  joint  within  the  capsular  space;  hence  we  find  primary 
defects  in  the  structure  of  the  joint,  and  secondary  changes  de- 
veloped by  the  use  of  the  defective  joint. 

PKIMAEY  DEFECTS. — (a)  Shallow  Acetabulum. — Instead  of  a 
cup-like  cavity  to  receive  the  head  of  the  femur  there  is  a  malforma- 
tion which  varies  from  a  shallow  saucer  to  a  mere  indentation.  The 
empty  cotyloid  cavity  is  filled  with  connective  tissue,  loses  its  depth 
and  spherical  form,  and  often  assumes  a  triangular  shape. 

(b)  Changes  in  upper 
end  of  femur  are  variable 
and  due  to  lack  of  develop- 
ment. The  head  is  small 
and  flattened.  Changes 
are  noted  in  the  angle  of 
the  neck,  usually  a  certain 
degree  of  coxa  vara,  the 
length  of  the  neck  is  di- 
minished and  sometimes 
wanting  altogether,  so  that 

the  head  rests  on  the  great  FIG.   238. — DIAGRAM  SHOWING  DISPLACED  FEMORAL 

HEAD  ON  THE  DORSUM  ILII. 

trochanter.     It  is  obvious 

that  the  condition  does  not  manifest  itself  at  birth,  but  passes  un- 
noticed until  the  child  begins  to  walk,  then  occur — 

SECONDARY  CHANGES  due  to  use  of  the  defective  joint.  It  is 
apparent  that  when  the  child  begins  to  walk  and  no  support  is 
offered  the  femoral  head  by  the  acetabulum,  it  becomes  permanently 
displaced  on  the  dorsum  ilii  (Fig.  238),  and  the  weight  of  the  body 
is  borne  by  the  capsule,  which  becomes  greatly  thickened,  stretched 
out  like  an  hour-glass-shaped  tube,  the  constriction  of  the  hour-glass 
separating  the  head  from  the  acetabulum,  which  forms  a  serious  ob- 
stacle to  reduction. 

It  is  evident  that  the  muscles  surrounding  the  hip-joint  must 
undergo  adaptive  changes  in  length  and  direction  consequent  upon 


606  CONGENITAL  DISLOCATION  OF  THE  HIP 

loss  of  bony  function.  These  changes  consist  of  shortening  and 
hypertrophy.  Other  secondary  effects,  such  as  asymmetry  of  the 
pelvis,  curvatures  of  the  spine,  and  loss  of  normal  muscular  balance, 
are  the  natural  sequence. 

Symptoms. — The  history  which  the  parents  give  shows  that  noth- 
ing abnormal  was  observed  until  the  child  began  to  walk;  that  the 
child  learned  to  walk  late;  that  he  walks  badly,  falls  easily,  and 
tries  to  sustain  himself  by  grasping  objects.  In  addition  to  this 
they  have  noticed  the  deformity  of  the  hip.  The  most  prominent 
symptom  is  the  "limping"  gait  of  the  patient,  present  both  in  uni- 
lateral and  bilateral  dislocations.  The  "limping"  of  unilateral  dislo- 
cation is  the  "waddling"  of  bilateral  dislocation. 

The  characteristic  "limping"  is  due  not  only  to  the  shortening, 
but  because  the  femoral  head  is  not  held  in  a  fixed  position  on  the 
bone  above  it — it  glides  up  and  down;  at  every  step  the  patient  takes 
the  body  gives  way,  and  on  inspection  the  up-and-down  movements 
of  the  trochanter  can  be  distinctly  seen. 

In  unilateral  congenital  dislocation  note  the  characteristic  "limp- 
ing" gait,  the  shortening,  the  trochanter  above  Nelaton's  line,  flat- 
tening of  the  buttock,  and  prominence  of  the  trochanter  on  the 
affected  side.  There  are  also  tilting  of  the  pelvis  to  correct  the  short- 
ening and  lateral  curvature  of  the  spine. 

On  examination  the  head  is  found  out  of  its  normal  position 
and  may  be  felt  displaced  upward  under  the  soft  parts  when  rolled 
about  by  manipulation.  It  will  also  be  found  that  there  are  normal 
flexion,  extension,  adduction,  rotation,  and  circumduction.  Abduc- 
tion only  is  found  to  be  limited  and  the  movement  is  suddenly  ar- 
rested. 

Bilateral  congenital  dislocation  of  the  hip  presents  the  same 
local  conditions  on  both  sides  (Fig.  239).  The  pelvis  seems  to  have 
penetrated  like  a  wedge  between  the  extremities,  which  appear  too 
short  when  compared  with  the  well-developed  trunk.  Two  promi- 
nent symptoms  confirm  the  diagnosis: 

(a)  The  patient's  gait.  The  patient  in  walking  "waddles"  like 
a  duck ;  with  each  step  the  body  sways  from  side  to  side — a  feature 
plainly  discernible  through  the  clothes. 


TEEATMENT 


607 


(b)  The  patient's  attitude.  There  is  a  well-marked  lordosis  of 
the  lumbar  spine  producing  a  condition  of  "saddle  back." 

The  affected  limbs  undergo  muscular  atrophy  and  the  deformity 
increases  with  age. 

An  important  observation  is  the  fact  that,  while  these  patients 
walk  incorrectly,  they  walk  without  more  fatigue  than  others. 

Diagnosis.' — With  a  suggestive  history  and  the  characteristic  gait 
of  the  deformity  the  diagnosis  usually  presents  no 
difficulties.     The  X-ray  is  the  most  direct  means 
of  dispelling  all  doubt. 

It  will  be  necessary  to  differentiate  coxa  vara 
which  gives  "limping"  gait,  trochanter  above  Ne- 
laton's  line,  and  shortening  of  the  extremity.  The 
gait,  however,  is  firmer  and  the  femoral  head  is  in 
its  normal  position. 

In  paralytic  dislocation  of  the  hip  (extremely 
rare)  there  are  displacement  of  the  head  and 
ascension  of  the  great  trochanter,  seen  in  the  his- 
tory of  infantile  paralysis;  but  the  least  traction 
on  the  extremity  is  sufficient  to  bring  the  head  into 
normal  position. 

In  hip-joint  disease  it  is  hardly  possible  to 
make  a  mistake  when  the  fixation  of  the  head  is 
considered,  the  painful  passive  movements,  and 
the  dragging  of  the  limb.  Besides  congenital  dis- 
location is  ruled  out  by  the  presence  of  fever, 
swelling,  abscess,  and  fistulization.  The  history, 
careful  examination,  and  finally  the  X-ray  will  insure  a  correct 
diagnosis. 

Prognosis. — When  untreated  the  dislocation  becomes  more  and 
more  aggravated  by  the  growing  weight  of  the  body — hence  walk- 
ing is  more  difficult  and  lordosis  and  scoliosis  more  accentuated. 
Under  proper  treatment  the  deformity  can  be  completely  cured. 

Treatment. — The  earlier  the  treatment  the  better.  If  it  is  pos- 
sible to  make  a  diagnosis  before  the  patient  walks,  treatment  may 
be  begun  by  preventing  further  development  of  the  deformity  and 


:G.  239. — BILAT- 
ERAL CONGENITAL 
DISLOCATION  OF 

THE  HlP  IN  A  BOY 

OF  FIFTEEN.  (Kir- 
misson.) 


608  CONGENITAL  DISLOCATION  OF  THE  HIP 

not  allowing  the  child  to  bear  its  weight  for  the  first  two  years. 
These  patients  are  usually  brought  to  the  physician  after  the  second 
year  when  there  is  pronounced  disturbance  in  walking.  Three 
methods  of  treatment  may  be  used. 

(a)  MECHANICAL,. — In  patients  too  old  to  permit  of  reduction 
a  corset  made  of  felt  with  silicate  of  soda  and  shellac  or  leather 
will  improve  the  patient's  gait  by  pressing  against  the  trochanter 
and  thus  prevent  the  head  from  slipping  upward  when  walking. 

(b)  BLOODLESS    REDUCTION. — Lorenz    employs    a    method    of 
manipulation  by  which  all  the  resisting  structures  are  over-stretched, 
the  head  of  the  femur  brought  to  the  level  of  the  acetabulum  and 
implanted  in  this  position,  where  it  is  held  by  a  plaster  splint  so 
arranged  that  as  the  limb  is  used  the  head  will  be  pressed  into  the 
cavity,  which  it  will  gradually  dilate,  deepen,  and  convert  into  a 
staple  joint.     The  age  of  election  for  this  procedure  is  from  three 
to  six  years,  though  in  unilateral  cases  it  may  be  tried  up  to  the 
twelfth  year. 

Method. — The  object  of  this  method  is  to  obtain  a  complete  ana- 
tomical reduction  and  to  retain  the  reduction  sufficiently  long  to 
establish  a  normal  and  permanent  articulation.  First,  the  patient 
is  deeply  anesthetized  to  the  point  of  complete  relaxation.  Second, 
manipulation  of  the  thigh  by  flexion,  extension,  rotation,  abduction, 
and  massage  to  overcome  the  resistance  in  the  shortened  muscles 
and  fascia  and  thus  by  over-stretching  these  tissues  eliminate  the 
obstacle  to  reduction.  The  steps  of  the  procedure  vary  with  different 
operators — the  result  is  the  same. 

The  method  of  Kirmisson  has  been  followed  by  the  authors  with 
excellent  results  and  is  essentially  as  follows:  An  assistant  holds 
the  pelvis  firmly  fixed  while  the  surgeon  proceeds  to  flex  the  thigh 
on  the  pelvis,  repeating  the  movement  until  the  head  of  the  femur 
is  brought  down  as  low  as  possible  and  in  relation  with  the  posterior 
and  inferior  portion  of  the  acetabulum.  Next  the  limb  is  slowly 
abducted,  and  in  this  position  it  will  be  found  that  the  shortened 
tendons  of  the  adductors  stand  out  prominently  beneath  the  skin. 
This  tension  of  the  adductors  must  be  made  to  yield  by  firm  and 
increasing  abduction  together  with  massage  until  the  thigh  in  forced 


TEEATMENT  609 

abduction  lies  on  its  external  surface,  even  though  some  of  the 
muscular  fibers  are  ruptured  (in  some  cases  it  is  necessary  to  divide 
the  tendon  of  the  adductor  longus). 

After  complete  abduction  is  obtained  the  limb  is  circumducted 
until  the  head  is  freely  movable. 

Thus  with  the  head  brought  as  low  as  possible  and  freely  mov- 
able, the  fascial  and  muscular  obstacles  having  been  removed  by 
over-stretching,  we  proceed  to — 

Reduction. — To  understand  the  movements  of  reduction  it  must 
be  remembered  that  the  Y-ligament  of  Bigelow  is  the  chief  aid  to 
the  surgeon  in  accomplishing  reduction,  since  it  acts  as  a  fulcrum 
to  the  shaft  of  the  bone,  the  diaphysis  being  the  long  arm,  and  the 
femoral  head  the  short  arm  of  the  lever.  Thus  every  movement  of 
the  knee  produces  an  opposite  movement  of  the  femoral  head. 

The  thigh  is  flexed — to  lower  the  head — then  abducted  and 
strongly  rotated  outward — by  this  movement  the  head  is  forced  over 
the  rim  of  the  acetabulum  and  a  sudden  "jump"  indicates  that  the 
head  has  reached  the  socket.  It  must  not  be  expected  that  a  reduc- 
tion can  be  accomplished  in  the  first  attempt.  Repeated  trials  are 
often  necessary,  combined  with  direct  pressure  on  the  great  tro- 
chanter.  When  the  head  is  finally  in  place  there  is  the  noticeable 
fulness  in  Scarpa's  triangle  and  the  head  can  be  felt  beneath  the 
crural  arch. 

After  reduction  it  is  necessary  that  the  head  be  maintained  in 
position  by — 

Fixation. — To  extend  the  limb  in  normal  position  after  reduc- 
tion is  only  to  invite  a  return  of  the  dislocation.  To  make  the  re- 
duction permanent  it  is  necessary  to  fix  the  limb  in  a  position  of 
flexion,  abduction,  and  external  rotation  for  a  period  sufficiently 
long  to  mold  the  muscles  and  joint  into  a  state  of  equilibrium  and 
stability.  To  attain  this  the  pelvis  and  thigh  must  be  fixed  in  a 
plaster  cast  extending  from  the  arch  of  the  ribs  to  the  knee. 

The  duration  of  fixation  in  this  position  is  variable  (from  three 
to  six  months)  and  depends  upon  the  ease  with  which  the  reduction 
is  maintained. 

During  this  period  the  child  is  permitted  to  walk  with  a  high 


610 


CONGENITAL  DISLOCATION  OF  THE  HIP 


sole  on  the  affected  leg  (Fig.  240).  If  the  retention  is  satisfactory 
the  bandage  should  be  removed  at  the  end  of  the  third  month;  the 
joint  examined  and  radiographed,  and  if  the  position  is  satisfactory 
a  second  plaster  bandage  is  applied  in  a  position  of  less  flexion  and 
abduction.  At  the  end  of  two  or  three  months  the  cast  is  again  re- 
moved, the  joint  examined,  and  the  cast  reapplied  with  the  limb  in 
normal  position. 

The  duration  of  fixation  varies  from  six  months  to  a  year.     It 

is  well  to  remember  that  empirical 
treatment  in  these  cases  is  impossible — • 
the  frequency  with  which  the  cast 
should  be  changed  and  the  modification 
of  the  position  of  the  limb  must  depend 
upon  the  case  and  the  dictates  of  ex- 
perience. After  the  cast  is  finally  re- 
moved the  child  is  permitted  to  walk 
with  crutches  so  as  to  use  the  limb 
without  weight.  The  joint  should  be 
gently  mobilized  and  the  limb  mas- 
saged. Later,-  an  active  gymnastic  ex- 
ercise to  improve  the  adductors  may  be 
of  great  advantage. 

Complications. — The  most  frequent 
accidents  occurring  in  bloodless  reduc- 
tion are : 

(a)  Fracture,  which  is  not  grave 
and  has  no  bad  influence  on  the  result. 
It  is  well  to  remember  that  this  may 
be  avoided  by  abstaining  from  violent 
movements. 

(b)  Ecchymosis  from  the  ruptured  fibers  of  the  over-stretched 
adductors,  which  is  absorbed  in  a  few  days. 

(c)  Vicious   Attitude. — Even    after    successful   reduction    it    is 
sometimes  found  that  a  twist  in  the  nock  of  the  femur  causes  a 
corresponding  vicious  attitude  in  the  axis  of  the  femur.     To  correct 
this  it  may  be  necessary  to  do  a  subtrochanteric  osteotomy. 


FIG.  240. — PLASTKR  FIXATION 
AFTER  REDUCTION  OF  A  CON- 
GENITALLY  DISLOCATED  HlP. 
(Bradford  and  Lovett.) 


TREATMENT  611 

In  bilateral  dislocation  the  treatment  remains  the  same  as  for 
unilateral  dislocation.  Both  hips  are  reduced  at  one  seance.  It  is 
well  to  remember,  however,  that  an  equally  good  result  on  both  sides 
is  rarely  obtained. 

(c)  REDUCTION  BY  INCISION  AND  MANIPULATION. — The  patient 
is  anesthetized  and  an  incision  made  from  the  anterior  superior 
spine  downward  and  passing  below  the  tip  of  the  great  trochanter 
(Lorenz).  The  fascia  lata  is  incised,  the  muscles  retracted,  and 
the  capsule  of  the  joint  exposed. 

The  capsule  is  now  split  and  the  opening  enlarged  so  as  to 
expose  freely  the  bony  structures.  If  the  head  is  held  by  the  liga- 
menturn  teres  it  should  be  excised  and  removed.  A  thorough  exami- 
nation of  the  parts  is  made  to  ascertain  the  conditions  which  pre- 
vent retention  of  the  head  in  the  acetabulum  and  these  obstructions 
removed. 

It  may  be  necessary  to  deepen  the  acetabulum  by  scooping  out 
the  dense  fibrous  tissue  which  sometimes  fills  it,  or  it  may  be  neces- 
sary to  round  out  the  flattened  head.  When  the  obstacles  to  reduc- 
tion have  been  removed  the  head  is  pried  into  the  acetabulum  and 
the  capsule  sutured  about  the  head  and  neck  so  as  to  act  as  a  means 
of  retention.  The  limb  should  be  retained  in  a  position  of  strong 
abduction  by  a  plaster  bandage  reaching  from  the  axilla  to  the  toes 
(Lovett). 

The  abduction  is  reduced  with  each  dressing  and  later  massage 
and  passive  movements  are  instituted.  The  operation  is  extensive 
and  severe — and  even  in  a  case  of  normal  healing  requires  a  high 
vital  resistance  on  the  part  of  the  patient. 

The  results  of  open  operation  cannot  approach  bloodless  reduc- 
tion. Besides  its  severe  strain  on  the  vital  forces,  it  is  often  fol- 
lowed by  disturbance  of  function  and  ankylosis. 


612  COXA  VARA  AND  COXA  VALGA 

CHAPTER  LXXIV 

COXA  VAKA  AND  COXA  VALGA 

COXA  VARA 

Coxa  vara  is  a  deformity  of  the  femoral  neck  manifested  by  a 
deficiency  in  the  normal  angle  which  is  formed  by  the  head  and 
neck  of  the  femur  with  the  shaft.  It  will  be  noted  that  normally 
the  neck  of  the  femur  forms  an  "angle  of  inclination"  with  the 
shaft  of  about  125°.  In  coxa  vara  the  angle  of  inclination  is  de- 
creased to  a  right  angle,  or  may  even  form  an  acute  angle  of 
60°-70°  (Fig.  241). 

There  is  also  some  deviation  in  the  normal  angle  which  the 
head  forms  with  the  neck.  This  is  usually  an  angle  of  about  12° 
pointing  backward.  In  coxa  vara  this  angle  is  increased. 

Etiology  and  Pathology. — In  considering  the  etiology  of  coxa 
vara  it  must  be  noted  that  the  normal  angle  of  inclination  of  the 
femoral  neck  is  a  product  of  the  upright  position.  In  quadrupeds 
and  the  anthropoid  apes  the  neck  remains  at  a  right  angle;  hence 
we  see  in  congenital  coxa  vara  a  reversion  to  a  lower  type.  We 
may  also  have  a  traumatic  coxa  vara  due  to  vicious  union  in  frac- 
tures of  the  neck  of  the  femur.  The  two  forms  of  coxa  vara  which 
concern  us  here  are  the  rachitic  coxa  vara  of  small  children  and  the 
coxa  vara  of  adolescents. 

It  is  evident  that  any  pathogenic  factor  that  modifies  the  nutri- 
tion of  the  bone  or  compromises  its  resistance  can  cause  coxa  vara. 
If  the  neck  of  the  femur  loses  its  resistance  it  bends  under  the  body 
weight,  hence  rachitis  plays  an  important  role  in  the  etiology  of  this 
affection. 

In  the  coxa  vara  of  adolescents  there  is  developed  at  the  age  of 
puberty  a  similar  deviation  due  either  to  defective  nutrition — late 
rickets — or  a  deviation  in  the  epiphyseal  line  between  the  neck  and 
the  head. 

Coxa  vara  may  be  either  unilateral  or  bilateral. 


COXA   VARA 


613 


Symptoms. — (a)  Pain,  which  is  often  reflected  to  the  knee  and 
foot.  It  disappears  in  repose  and  appears  when  the  patient  walks. 
This  pain  is  due  to  abnormal  tension  upon  the  muscles  and  liga- 
ments. 

(b)  Impairment  of  function.  There  is  a  disturbance  of  gait. 
The  patient  "limps,"  and  in  bilateral  affections  "wabbles"  like  con- 
genital hip-joint  dislocation.  The  affected  leg  tires  easily,  and  there 
are  manifest  the  defects  due  to  shortening  and  to  the  disturbance  in 
the  muscle  mechanism  caused  by  the  displacement 
of  the  trochanter  above  Nelaton's  line. 

ON  EXAMINATION  we  find  that  the  limb  is 
shortened,  adducted,  and  rotated  outward.  The 
greater  trochanter  is  above  Nelaton's  line  and  the 
head  of  the  femur  is  in  its  normal  place.  There 
are  limitation  of  the  movements  of  abduction  and 
internal  rotation. 

Abduction  is  prevented  by  the  shortened  ad- 
ductors and  the  bony  interference  caused  by  the 
high  position  of  the  trochanter. 

Diagnosis. — When  the  history  is  carefully  con- 
sidered the  diagnosis  is  not  difficult.  The  prin- 
cipal diagnostic  signs  are  shortening  of  the  ex- 
tremity and  displacement  of  the  trochanter  above 
Nekton's  line  without  displacement  of  the  femoral 
head. 

When  the  trouble  exists  from  birth  it  must  be 
differentiated  from  congenital  dislocation  of  the  hip  by  the  more 
secure  gait,  the  recognition  of  the  head  in  its  normal  position;  and 
finally,  the  X-ray  will  determine  the  exact  diagnosis  and  should 
never  be  omitted. 

When  the  affection  occurs  during  early  adolescence  it  must  be 
differentiated  from  hip-joint  disease  by  its  rapid  onset,  absence  of 
constitutional  symptoms  or  muscular  rigidity,  and  early  occurrence 
of  shortening. 

Prognosis. — While  the  progress  of  the  disease  may  be  checked 
under  proper  treatment  it  must  be  understood  that  such  resulting 


FIG.  241.— COXA 
VAKA. 


614         COXA  VARA  AND  COXA  VALGA 

deformity  as  changes  in  the  bone  have  established  is  permanent,  and 
that  function  is  modified  according  to  the  degree  of  deformity. 

Treatment. — Rest  in  bed  with  continuous  traction  of  the  limb 
in  a  position  of  abduction,  using  such  drugs  as  favorably  influence 
the  formation  of  bone,  and  out-of-door  life.  When  the  symptoms 
have  disappeared  the  use  of  the  limb  should  be  resumed  gradually 
and  with  the  use  of  crutches.  When  there  are  marked  deformity  and 
impairment  of  function  it  will  be  necessary  to  resort  to  operative 
measures,  as  subtrochaiiteric  osteotomy. 

COXA  VALGA 

Coxa  valga  is  a  deformity  of  the  femoral  neck  in  which  the 
angle  of  inclination  is  increased  and  the  normal  obliquity  of  the 
neck  exaggerated.  In  some  cases  of  coxa  valga  the  X-ray  shows 
that  the  angle  of  inclination  is  so  exaggerated  that  the  shaft  and 
the  neck  of  the  femur  appear  to  be  in  a  continuous  line. 

Etiology. — Coxa  valga  may  be  congenital  or  acquired.  The  con- 
genital type  may  occur  in  conjunction  with  or  without  congenital 
dislocation  of  the  hip. 

Acquired  coxa  valga  is  usually  the  result  of  continuous  traction 
by  "dead  weight"  from  below  and  is  found  frequently  in  infantile 
paralysis,  or  in  the  pendent  stump  of  a  thigh  amputated  in  early 
childhood.  It  is  seen  on  the  opposite  side  of  a  genu  valgum,  after 
fracture  of  the  neck  of  the  femur  with  impaction  and  vicious  union, 
and  after  injuries  and  separation  of  the  epiphysis  (Tubby). 

Symptoms. — When  it  is  remembered  that  the  absence  of  weight- 
bearing  is  an  important  etiological  factor,  it  is  obvious  that  the  de- 
formity is  most  frequently  found  in  an  unused  extremity  and  hence 
the  symptoms  are  obscure.  The  limb  is  in  a  position  of  abduction 
and  external  rotation  with  corresponding  limited  adduction  and  in- 
ward rotation.  There  is  lengthening  with  pain  and  lameness. 

Diagnosis. — The  X-ray  is  necessary  in  making  an  exact  diagnosis. 

Treatment. — Osteotomy  of  the  neck  of  the  femur  with  fixation 
in  adduction  is  indicated  for  the  purpose  of  restoring  the  normal 
angle  between  the  femoral  neck  and  shaft. 


PATHOLOGY  615 

CHAPTER  LXXV 

HIP-JOINT    DISEASE 

Hip-joint  disease  (tuberculosis  of  the  hip,  coxalgia)  is  essen- 
tially a  disease  of  childhood  and  one  of  the  most  common  forms  of 
joint  tuberculosis.  It  most  frequently  attacks  children  between 
the  ages  of  five  and  ten  years  and  is  generally  unilateral.  It  be- 
gins either  as  a  tuberculosis  of  the  synovial  membrane,  or  as  a 
tuberculous  osteomyelitis  of  the  head  of  the  bone  or  the  acetabulum. 

Whatever  the  initial  focus,  a  destructive  process  is  inaugurated 
in  the  joint,  in  which  the  onset  is  insidious,  the  development  slow, 
and  the  symptoms  pronounced  only  when  the  disease  is  well  ad- 
vanced. It  is  a  disease  that  presents  a  problem  of  great  difficulty 
and  responsibility,  it  demands  the  closest  attention  of  the  medical 
adviser  since  successful  treatment  depends  upon  early  diagnosis. 

Pathology. — The  tuberculous  process  in  the  hip  is  similar  to  that 
in  other  joints.  The  disease  spreads  from  its  primary  focus  and 
invades  the  joint,  filling  it  with  granulations  and  destroying  the 
joint  mechanism.  The  whole  head  and  neck  undergo  slow  disin- 
tegration and  under  the  superimposed  weight  sometimes  fracture 
and  leave  the  head  lying  in  the  acetabulum  like  a  sequestra. 
Though  more  resistant,  the  acetabulum  is  affected  likewise,  and,  as 
the  bony  tissue  softens,  the  head,  by  the  action  of  the  weight,  is 
pushed  more  and  more  upward  into  the  softened  acetabulum,  which 
enlarges,  and  later  the  head  is  dislocated. 

After  caseation  and  suppuration  the  abscess  perforates  the  cap- 
sule and  appears  superficially  in  the  region  of  the  trochanter,  at  the 
lower  border  of  the  glutei,  or  into  the  pelvic  cavity  if  it  perforates 
the  acetabulum.  Cure  of  the  disease  is  accomplished  by  scar  forma- 
tion, resulting  in  fibrous  and  sclerotic  changes  in  the  elements  of  the 
joint.  It  is  evident  that  complete  restitution  of  function  can  be 
expected  only  in  the  early  stages  of  hydrops  articuli ;  in  all  other 
cases  the  cure  implies  varying  degrees  of  functional  disability. 


616  HIP-JOINT    DISEASE 

Both  the  bone  and  the  muscles  show  marked  nutritional  dis- 
turbances, the  muscles  of  the  thigh  undergoing  marked  atrophy.  It 
is  evident  that  arrest  of  development  of  the  extremity  and  vitiation 
of  the  pelvis,  of  grave  import  to  the  female,  are  among  the  remote 
consequences. 

Symptoms. — As  the  disease  begins  insidiously  every  effort  should 
be  made  to  anticipate  its  progress  by  a  correct  interpretation  of  its 
earliest  indications.  Note  the  important  fact  that  the  onset  of  the 
disease  is  rarely  acute,  and  that  it  frequently  makes  its  appearance 
in  children  apparently  in  vigorous  health. 

Again,  the  earliest  symptoms  are  not  the  direct  symptoms  of  a 
diseased  joint,  they  are  the  reflex  symptoms  of  disease  in  the  neigh- 
borhood of  the  joint. 

(a)  Lameness. — The  earliest  appreciable  symptom  of  hip  disease 
is  a  slight  limp,  and  for  months  this  is  sometimes  the  only  symptom. 
Note  that  the  lameness  at  first  is  indefinite  and  intermittent.  The 
child  makes  every  effort  to  favor  the  affected  limb,  he  drags  rather 
than  moves  the  leg  along,  and  the  mother's  observations  are  invalu- 
able to  the  surgeon  in  correlating  this  data. 

She  observes  that  the  child  does  not  use  one  limb  with  the  same 
freedom  as  the  other.  That  when  the  child  stands  at  rest  he  invari- 
ably stands  on  the  healthy  limb — a  fact  confirmed  by  examination — 
and  associated  with  this  it  is  noted  that  the  knee  of  the  affected  side 
is  slightly  flexed  and  the  thigh  slightly  abducted. 

This  position  of  abduction  is  the  inevitable  position  assumed  to 
avoid  painful  weight-bearing,  by  shifting  the  leg  from  the  axis  of 
weight. 

The  mother  has  noticed  that  the  rhythm  of  the  gait  is  broken — 
there  is  an  inequality  in  duration  and  intensity  of  the  gait,  the 
patient  remains  longer  on  the  healthy  limb  and  puts  the  foot  to  the 
ground  with  more  force ;  hence  the  ear  alone  can  detect  the  arhythmic 
gait.  Furthermore,  it  is  observed  that  there  is  a  certain  amount 
of  stiffness  of  gait  in  the  morning  immediately  after  getting  out  of 
bed,  which  gradually  wears  off  as  the  joint  "limbers  up"  and  be- 
comes pronounced  again  toward  night  when  the  child  is  fatigued. 

The  manifestation  of  early  lameness  is  therefore  often  a  vary- 


SYMPTOMS  617 

ing  expression  of  rest  or  fatigue — a  limitation  of  motion  for  the 
purpose  of  resting  and  protecting  the  joint. 

(b)  Pain. — While  pain  is  among  Hie  early  symptoms,  it  is  not 
a  constant  symptom  and  may  be  absent  at  any  stage  of  the  disease. 
The  pain  may  be  constant  or  intermittent  and  usually  appears  after 
the  fatigue  of  a  long  walk,  or  is  manifest  in  night  cries. 

The  peculiarity  of  the  pain  of  early  hip  disease  is  the  fact  that 
the  pain  is  at  first  referred  to  the  knee.  This  phenomenon  is  ex- 
plained by  the  distribution  of  the  obturator  nerve  which  supplies 
both  the  hip  and  the  knee  joints.  Irritation  of  the  nerve  at  the  hip 
is  expressed  in  pain  at  the  knee.  Hence  when  a  child  complains  of 
pain  at  the  knee  (especially  if  accompanied  by  slight  limp)  do  not 
consider  it  insignificant.  It  may  be  the  initial  symptom  of  a  grave 
malady  of  the  hip  joint. 

Again,  if  upon  examination  of  the  knee  there  is  found  no  lesion 
which  explains  the  pain,  suspect  that  it  is  a  sympathetic  phenomenon 
connected  with  tuberculous  hip.  The  pain  may  be  increased  by  any 
movement  which  causes  pressure  on  the  joint  surfaces,  demonstrated 
by  exercising  pressure  on  the  trochanter,  the  knee,  or  sole  of  the 
foot.  Sudden  pain  at  night,  sufficient  to  wake  the  child  with  a  cry, 
is  characteristic,  and  due  to  sudden  muscular  spasm,  for  during  the 
day  the  muscles  are  on  guard  and  immobilize  the  joint,  but  when 
the  child  is  asleep  the  joint  is  unprotected  and  slight  movement 
affects  the  unguarded  joint. 

Note  that  pain  and  limp  are  not  necessarily  simultaneous.  Some- 
times there  is  no  pain  but  slight  limp,  or  there  may  be  no  limp  but 
slight  pain. 

(c)  Muscular  spasm  is  the  most  important  early  symptom  of 
hip  disease,  and  when  combined  with  pain  and  limp  the  diagnosis 
is  unmistakable;  for  muscular  spasm  to  some  degree  is  never  absent 
even  at  the  beginning  of  the  disease. 

All  attempts  at  movement  are  followed  by  muscular  spasm — an 
effort  to  fix  the  affected  joint  by  reflex  contraction  of  the  muscles. 
Finally  all  movements  are  restricted  and  the  hip  is  fixed  in  an 
abnormal  typical  position.  In  the  early  stage,  however,  the  limi- 
tations of  motion  are  entirely  the  result  of  muscular  spasm,  since 


618 


HIP-JOIXT    DISEASE 


under  anesthesia  all  the  movements  are  restored  to  the  normal. 
Muscular  spasm  is  not  only  the  most  important  symptom  in  diag- 
nosis, but,  as  Bradford  and  Lovett  observe,  it  furnishes  the  most 
accurate  index  of  the  progress  of  the  case  and  improves  or  becomes 
worse  as  the  affected  joint  improves  or  deteriorates. 

As  the  disease  progresses  the  child  avoids  walking  as  much  as 

possible,  prefers  to  sit  or 
lie  in  bed. 

(d)  Muscular  Atrophy. 
— The  muscles  of  the  af- 
fected limb  early  show  a 
diminution  in  size,  easily 
detected  by  measuring  the 
circumference  of  the  two 
thighs  and  calfs.     A  dif- 
ference of  one-half  to  one 
and  one-half  inches  may  be 
demonstrated.    Early  atro- 
phy  of   the    muscles   con- 
trolling a  joint  is  pathog- 
nomonic  of  joint  disease. 

(e)  Flattening  of  the 
buttock  and  loss  of  the  glu- 
teal    fold    (Fig.    242)    is 
due  to  flexion  of  the  hip 
combined  with  atrophy  of 
the    gluteal    muscles.      A 
comparison     of     the     two 
sides    shows    a    striking 

contrast  in  the  obliteration  of  the  fold  on  the  affected  side. 

(f)  Malpositions. — As  a  result  of  an  effort  on  the  part  of  the 
patient  to  assume  an  attitude  of  greatest  comfort,  and  the  subsequent 
muscular  contractions  in  the  faulty  positions,  there  is  ultimately 
produced  fixation  of  the  limb  in  an  abnormal  position,  i.  e.,  the 
limb  is  fixed  in  various  positions  of  flexion,  abduction,  adduction, 
and  eversion ;  or  in  various  combinations  of  one  with  the  other,  there 


FIG.  242. — OBLITERATION  OF  THE  GLUTEAL  FOLD 
IN  DISEASE  OF  THE  RIGHT  HIP. 


SYMPTOMS 


619 


being  no  regular  order  in  which  these  faulty  positions  make  their 
appearance. 

The  results  of  malpositions  and  their  effect  on  the  pelvis:  It  is 
important  to  understand  that  the  fixation  of  the  limb  in  a  distorted 
position  is  always  followed  by  tilting  of  the  pelvis — a  compensation 
necessary  to  make  the  limbs  parallel  and  thus  permit  the  patient  to 
walk  or  stand  on  both  feet  (Fig.  243). 

This  can  be  demonstrated  easily  by 
means  of  a  simple  diagram.  Normally 
both  limbs  are  at  right  angles  to  the  pel- 
vis as  shown  in  diagram  (Fig.  244A). 
Assume  now  that  the  right  leg  repre- 
sented by  the  line  a  c  is  fixed  in  a 
faulty  position  of  adduction  a  e,  it  is 
evident  that  the  two  limbs  represented 
by  the  lines  a  e  and  b  d  cannot  be 
brought  into  a  parallel  relation  without 
tilting  the  pelvis  represented  by  the  line 
a  b,  with  the  resultant  position  as 
shown  in  Fig.  244B.  For  it  must  be  re- 
membered that  the  adjustment  is  not 
done  in  the  diseased  joint,  but  in  the 
healthy  joint  which  adapts  itself  by  as- 
suming a  position  of  abduction  in  order 
to  be  brought  into  a  parallel  position 
with  the  permanently  adducted  leg. 

Again,  assume  the  right  leg  repre- 
sented by  the  line  a  c,  as  shown  in  Fig. 
244C,  is  fixed  in  a  faulty  position  of  abduction  a  e  it  is  evident  that 
the  lines  a  e  and  ~b  d  cannot  be  brought  into  a  parallel  relation 
without  tilting  the  pelvis  a  ~b,  with  the  resultant  position  as  shown 
in  Fig.  244D.  ISTow  note  the  second  important  fact:  namely, 
that  the  adducted  leg  a  c  with  the  tilting  of  the  pelvis  was  carried 
upward  with  that  side  of  the  pelvis  and  appears  to  be  shorter  than 
the  leg  b  d;  but  it  must  be  noted  that  this  is  only  apparent,  since  the 
legs  a  c  and  b  d  really  measure  the  same  length. 


FIG.  243. — THE  RESULTS  OF  MAL- 
POSITIONS AND  THEIR  EFFECT 
ON  THE  PELVIS. 


620 


HIP-JOINT   DISEASE 


b 


Again,  the  abducted  leg  a  c  with  the  tilting  of  the  pelvis  is  car- 
ried downward  with  that  side  of  the  pelvis  and  appears  to  be  longer 
..  than  the  leg  I)  d,  but  it  is  only 

|  apparent  since  the  lines  represent- 

ed ing   the   legs   really  measure   the 

same  length. 

Hence,  apparent  shortening  is 
an  inequality  of  the  legs  caused 
by  tilting  of  the  pelvis,  and  de- 
pendent upon  the  amount  of  ad- 
duction or  abduction.  It  is  best 
demonstrated  by  measuring  from 
the  umbilicus  to  each  internal  mal- 
leolus. 

Meal  shortening  is  not  a  po- 
sitional condition,  but  an  actual 
affection  of  the  limb,  the  result  of 
retarded  growth  or  disease  of  the 

/  joint.     It  is  always  demonstrated 

by  measuring  from  the  anterior 
superior  iliac  spine  to  the  internal 
malleolus. 

Flexion  of  the  thigh  is  very 
characteristic  of  early  hip  disease.  It  is  observed  in  the  attitude 
of  the  patient  as  he  lies  with  the  knee  of  the  affected  side  flexed 
(Fig.  245). 


Fio.  244. — DIAGRAM  DEMONSTRATING 
THE  EFFECTS  OF  MALPOSITIONS  OF 
THE  LlMBS  ON  THE  PELVIS. 


FIG.  245. — WHEN  THE  PATIENT  LIES  ON  His  BACK  THE  KNEE  OF  THE  AFFECTED  SIDE  is 

FLEXED. 


Fixation  of  the  thigh  in  the  position  of  flexion  is  demonstrated 
by  placing  the  patient  upon  a  table  flat  on  his  back  and  extending 
the  diseased  limb  until  it  is  in  contact  with  the  table  (Fig.  246). 


DIAGNOSIS  621 

Observe  that  in  order  to  maintain  the  fixed  flexion  the  pelvis  must 
tilt  forward  with  a  resultant  arching  upward  of  the  lurnbosacral 
vertebrae.  This  is  the  compensation  lordosis  of  the  lumbar  spine 
which  invariably  accompanies  fixed  flexion  in  hip  disease. 

(g)  Swelling. — Thickening  of  the  tissues  about  the  hip-joint  is 
corroborative  evidence  of  disease.  There  are  often  dense  infiltration, 
marked  swelling  and  fluctuation  when  abscess  presents.  The 
inguinal  glands  are  often  enlarged  and  after  a  time  suppurate  and 
discharge. 

(h)  Abscess. — During  the  course  of  the  disease  the  granulation 
tissue  caseates,  then  suppurates:  The  pus  perforates  the  capsule, 
burrows  along  the  line  of  least  resistance,  and  leaves  discharging 
sinuses  opening  on  the  front  and  side  of  the  thigh,  the  buttock  or 
perineum.  Occasionally  perforation  of  the  acetabulum  occurs  and 


PIG.  246. — WHEN  THE  DISEASED  LIMB  is  EXTENDED  THE  BACK  is  ARCHED  AS  THE  PELVIS 
TILTS  FORWARD  TO  MAINTAIN  THE  FIXED  FLEXION. 

an  abscess  is  formed  within  the  pelvis  which  may  point  above 
Poupart's  ligament,  about  the  rectum  or  ischiorectal  fossa. 

Early  and  efficient  treatment  precludes  the  possibility  of  abscess 
formation. 

Diagnosis. — Remember  that  early  diagnosis  is  essential  to  favor- 
able prognosis  and  successful  treatment.  The  most  important  early 
symptom  of  hip  disease  is  muscular  spasm  and  when  combined  with 
pain  and  limp  the  diagnosis  is  unmistakable.  As  Valette  asserts, 
there  can  be  no  hip  disease  if  the  movements  at  the  hip  are  perfect, 
any  difference  in  the  range  of  motion  of  the  two  hips  suggests 
disease.  After  the  disease  is  well  established  the  train  of  symp- 
toms as  described  above  present  a  vivid  picture. 

EXAMINATION  OF  PATIENT. — First  get  a  detailed  history  of  the 
case  from  the  parents.  Note  specially  what  they  have  observed. 
These  patients  present  a  typical  history  of  a  gradual  onset  of  lame- 


622  HIP-JOINT    DISEASE 

ness,  stiffness  of  the  hip,  a  disposition  to  favor  one  side,  pain  at 
the  knee.  The  temperature  should  be  taken.  The  clothes  should 
then  be  removed  and  the  attitude  of  the  patient  observed  in  stand- 
ing, walking,  lying  down,  and  getting  up. 

Ask  the  patient  to  stand  on  one  leg,  it  will  be  difficult  for  the 
patient  to  stand  on  the  affected  leg.  Mark  the  position  of  the  two 
anterior  superior  iliac  spines  upon  the  skin  with  ink  and  note  the 
compensatory  tilting  of  the  pelvis.  Remember  that  adduction  causes 
apparent  shortening,  abduction  apparent  lengthening. 

Place  the  patient  in  the  dorsal  position  upon  a  hard  table  (not 
bed)  and  direct  the  examination  so  as  to  ascertain  if  there  is  any 
diminution  in  the  physiological  movements  of  the  joint. 

Before  touching  the  patient  make  a  note  of  the  facts  that  can 
be  observed  by  a  preliminary  inspection.  If  there  is  fixed  flexion 
the  patient  lies  with  the  knee  of  the  affected  side  flexed. 

When  the  child  is  asked  to  extend  the  limbs  in  a  parallel  posi- 
tion the  back  will  be  arched  (lordosis  of  the  lumbar  spine)  if  a 
fixed  flexion  position  exists;  when  the  leg  returns  to  the  flexed 
position  the  arched  back  disappears — evidence  that  the  normal  arc 
of  motion  of  the  joint  is  limited.  After  the  preliminary  inspection 
grasp  the  lower  part  of  the  leg  with  one  hand  and  the  pelvis  with 
the  other  and  by  gentle  manipulation  test  all  the  movements  of  the 
joint,  first  in  the  normal,  then  in  the  suspected  limb  to  detect 
muscular  spasm.  During  each  movement  it  is  important  to  dis- 
tinguish between  normal  motion  in  the  joint  and  movement  of  the 
pelvis. 

Note  that  these  manipulations  are  for  the  purpose  of  appreciat- 
ing the  slightest  amount  of  muscular  spasm;  hence  they  should  bo 
gentle  and  steady.  Gentle  manipulation  will  not  only  cause  the 
patient  the  least  discomfort  but  it  will  give  the  most  accurate  in- 
formation concerning  muscular  spasm.  First  test  the  normal  range 
of  motion  in  the  healthy  joint — try  successively  flexion,  extension, 
abduction,  internal  and  external  rotation.  In  this  preliminary  ex- 
amination the  child  becomes  accustomed  to  the  manipulations. 
Then  examine  the  suspected  joint.  It  will  be  found  that  the  range 
of  movement  on  the  diseased  side  is  diminished,  and  when  an 


DIAGNOSIS 


623 


attempt  is  made  to  go  beyond  certain  limits  it  causes  pain  or  com- 
pensatory movement  of  the  pelvis. 

Now  note  how  the  diminished  movement  affects  the  pelvis.  It 
will  be  observed  that  when  the  leg  of  the  affected  side  is  brought  in 
full  extension  there  is  produced  a  lordosis  of  the  lumbar  spine.  ( See 
Fig.  246.)  Now  flex  the  affected  leg,  and  when  the  angle  of  flexion 
reaches  a  certain  degree  it  will  be  noted  that  the  lordosis  is  elimi- 
nated (Fig.  247).  The  angle  of  flexion  at  which  this  occurs 
measures  the  amount  of  fixed  flexion  deformity. 

Next  abduct  the  leg  and  note  the  point  at  which  the  pelvis  be- 


FIG.  247. — DISEASED  HIP  FLEXED  UNTIL  LORDOSIS  OF  THE  SPINE  is  OBLITERATED  SHOWING 
THE  AMOUNT  OF  FIXED  FLEXION  DEFORMITY. 

gins  to  move.  Try  internal  and  external  rotation  and  observe  the 
limitation  of  motion.  Note  the  presence  or  absence  of  pain  when 
pressure  is  made  over  the  trochanter  or  upon  the  sole  of  the  extended 
leg.  Look  for  swelling  over  the  trochanter,  Scarpa's  space,  the 
inguinal  glands. 

Measure  the  length  of  the  limbs  (being  sure  that  the  limbs  are 
placed  in  absolutely  symmetrical  position)  for  shortening.  Measure 
the  circumference  of  both  limbs  at  the  middle  of  the  thighs  and 
calfs  for  atrophy. 

Having  recognized  the  early  stages  of  hip  disease,  the  later  posi- 
tion changes  offer  no  difficulties. 


624  HIP-JOINT    DISEASE 

It  must  not  be  forgotten  that  in  the  X-ray  we  have  a  valuable 
aid  in  diagnosis.  At  the  beginning  of  the  disease  it  will  show  an 
enlargement  of  the  joint;  later,  changes  in  contour  of  the  joint 
bodies,  destruction  of  bone,  and  eventual  changes  in  the  normal 
position  of  the  head  and  acetabulum  which  form  the  basis  of  real 
shortening. 

Differential  Diagnosis. — Tubercular  disease  of  the  hip  should  be 
differentiated  from: 

(a)  Acute  osteomyelitis  of  the  hip  by  the  latter's  acute  onset— 
the  clinical  picture  of  an  acute  infection  as  seen  in  the  pain,  swell- 
ing, temperature,  leukocytosis,  and  general  sepsis. 

(b)  Pott's  disease  of  the  lumbar  spine  is  often  difficult  to  dif- 
ferentiate  and   the   diagnosis   must   sometimes   be   postponed   until 
characteristic    symptoms    of    one    or    the    other    disease    present. 
(See  p.  454.)     The  confusing  factor  is  the  contraction  of  the  psoas 
muscle  which  may  cause  lameness  by  limiting  motion.     The  limita- 
tion of  motion,  however,  is  confined  to  hyperextension :    Abduction, 
adduction,  and  rotation  are  not  restricted. 

Again,  in  Pott's  disease  there  is  rigidity  of  the  lumbar  spine 
and  extension  of  the  limb  causes  no  compensatory  lordosis.  Every 
movement  of  the  patient  demonstrates  the  effort  being  made  to  keep 
the  inflamed  spine  absolutely  rigid. 

The  formation  of  a  psoas  abscess  may  present  a  picture  of 
flexion  contracture  in  the  hip-joint,  but  the  other  hip  movements 
except  extension  are  free.  Examination  of  the  lumbar  vertebrae 
will  reveal  some  tenderness  and  usually  some  deformity. 

(c)  Trochanteric    Bursitis. — The    bursa    situated    between    the 
trochanter  and  tendon  of  the  gluteus  maximus  may  when  inflamed 
give  rise  to  symptoms  simulating  hip  disease,  since  the  pain  causes 
the  thigh  to  be  fixed  in  the  flexed  and  adducted  position.     It  should 
be  differentiated  by  the  absence  of  pain  in  the  joint  itself  and  the 
ability  to  rotate  the  head  of  the  femur  without  limitation  or  pain. 

(d)  Traumatic    affections    are    differentiated    by    the    history, 
course,  and  aid  of  the  X-ray. 

(e)  Rarely  will   it   be   necessary   to    differentiate   arthritis   de- 
formans,    coxa    vara,    appendicitis,    perinephritis,    and    malignant 


TEEATMENT  625 

disease  of  the  hip.  Their  symptoms  are  discussed  under  the  ap- 
propriate headings. 

Prognosis. — Untreated,  the  end  results  of  hip  disease  present 
striking  deformities,  changes  in  the  bony  conformation  of  the  joint 
which  lead  to  dislocation,  usually  backward,  with  actual  shortening; 
while  the  patient  may  finally  succumb  to  progressive  emaciation 
from  the  discharging  sinuses,  amyloid  changes  in  the  viscera,  or 
tuberculous  meningitis. 

A  favorable  termination  is  by  resolution  or  by  ankylosis.  Early 
recognition  and  early  treatment  will  shorten  the  course  of  the 
disease  and  offer  a  better  functional  prognosis.  The  duration  of 
the  disease  is  rarely  less  than  two  years,  and  often  the  diseased  can 
be  regarded  as  cured  only  after  four  to  six  years. 

Before  beginning  the  treatment  of  a  case  of  hip  disease  state 
s  clearly  that  the  disease  is  noted  for  its  chronicity,  that  treatment  is 
a  matter  of  years,  and  that  recovery  without  some  lameness  is 
impossible. 

Treatment. — Too  much  emphasis  cannot  be  placed  upon  the 
fundamental  principle  that  we  are  treating  the  local  expression  of 
a  general  condition.  The  local  lesions  whether  in  bone  or  joint  are 
only  the  local  evidence  of  a  debilitated  body.  Of  paramount  impor- 
tance then  is  the  general  treatment  of  the  child  to  so  improve  the 
tissues  that  the  tubercle  bacilli  will  cease  to  thrive.  General  treat- 
ment consists  in  proper  nutrition,  unlimited  sunshine  and  fresh  air. 

Locally  the  indications  in  hip  disease  call  for  rest,  traction, 
fixation,  and  protection.  This  treatment  must  cover  a  long  and 
trying  period,  testing  the  patience  of  surgeon  and  parents ;  effective 
cooperation  can  only  be  obtained  when  parents  have  an  intelligent 
conception  of  the  course  of  the  disease  and  the  value  of  early  im- 
mobilization in  effecting  a  cure  with  the  least  amount  of  functional 
impairment.  It  is  evident  that  the  social  position  of  the  child  plays  a 
great  part  in  the  efficiency  of  all  local  treatment,  since  the  best  treat- 
ment in  bad  surroundings  must  be  followed  by  disappointing  results. 

The  treatment  of  these  cases  should  be  under  the  direction  of 
those  specially  fitted  by  training  and  experience.  The  indications 
for  treatment  involve  nice  questions  of  judgment  which  can  be 


626  HIP-JOINT    DISEASE 

acquired  only  by  experience.  The  treatment  can  be  merely  out- 
lined in  a  general  way: 

It  is  evident  that  the  first  indication  is  rest  to  the  inflamed 
joint,  such  rest  as  can  be  obtained  by  preventing  the  inflamed  sur- 
faces from  coming  in  contact  and  thus  diminishing  reflex  muscular 
spasm ;  rest  that  is  uninterrupted  and  as  nearly  absolute  as  possible. 

The  patient,  therefore,  should  be  placed  in  a  recumbent  position, 
not  in  a  bed,  which  permits  tossing  about,  but  on  an  apparatus 
such  as  the  gas-pipe  frame  of  Bradford  and  Lovett,  which  per- 


Fio.  248. — EXTENSION  APPLIED  ON  WHEELED  LITTER.  (Merrill.) 

mits  the  child  to  be  carried  into  the  open  air  (an  oblong  frame 
made  of  gas  pipe  across  which  is  stretched  canvas  tightly  laced  to 
the  side  bars  and  made  in  two  sections  with  a  separation  of  several 
inches  opposite  the  arms),  or  upon  a  wheeled  litter  which  permits 
the  patient  to  be  placed  out  of  doors  and  kept  there  night  and  day 
if  possible  (Fig.  248). 

In  this  position  the  patient  should  be  kept  day  and  night  and 
traction  of  from  five  to  fifteen  pounds  applied  by  means  of  Buck's 
extension. 

The  traction  should  pull  in  the  line  of  deformity,  and  the  amount 


TEEATMENT 


627 


of  weight  be  increased  until  the  pain  ceases.  The  aim  of  traction  is 
to  pull  and  keep  the  inflamed  joint  surfaces  apart  until  the  inflam- 
matory process  has  subsided,  the  muscular  spasm  abated,  and  the 
deformity  is  reduced.  When  this  condition  has  been  attained  (in 
from  three  to  six  months),  and  attested  by  gradually  taking  off  the 
weight  without  recurrence  of  symptoms  for  at  least  three  months, 
the  recumbent  treatment  should  be  followed  by  the  ambulatory 
method,  which  combines  traction  and  fixa- 
tion and  also  permits  the  patient  to  get 
about  on  crutches:  thus  combining  the 
benefits  of  fresh  air  and  that  of  rest  to  the 
joint. 

The  requirements  of  this  treatment  are 
amply  fulfilled  by  the  Taylor  traction 
splint  (Fig.  249),  which  consists  of  a  pel- 
vic band  attached  to  which  is  an  adjustable 
metal  upright  with  a  rectangular  foot  piece. 
The  pelvic  band  passes  around  the  pelvis 
below  the  anterior  superior  spines  and  the 
two  attached  perineal  straps  furnish  coun- 
ter-traction. 

Extension  is  secured  by  means  of  ad- 
hesive straps  applied  from  the  middle  of 
the  thigh  to  the  maireoli  and  fastened  to  the 
straps  on  the  foot  piece  of  the  splint. 

The   patient  should  wear  a  high  shoe 

three  inches  thick  on  the  sound  side  and  use  crutches  so  that  the 
splint  swings  clear  of  the  ground.  The  splint  should  be  worn  day 
and  night  and  changed  only  when  required  for  purposes  of  cleanli- 
ness (Lovett).  As  to  the  length  of  time  for  which  splints  are  indi- 
cated, Von  Bergmann's  rule  is  of  general  application:  "Splints 
are  worn  until  the  joint  is  not  sensitive  to  the  body  weight  or  to  a 
blow  on  the  head  of  the  trochanter." 

Upon  the  recurrence  of  pain  or  acute  symptoms  the  patient 
should  at  once  be  returned  to  the  recumbent  position  with  traction ; 
and  it  must  be  remembered  that  in  an  apparently  healed  process  the 


FIG.  249. — THE  TAYLOR 
HIP-SPLINT.  (Keen's  Sur- 
gery.) 


628  FRACTURES  OF  THE  FEMUR 

infection  may  still  be  latent  and  threaten  a  renewal  of  the  process. 
Hence  in  keeping  the  joint  immobilized  it  is  better  to  err  on  the 
side  of  conservatism,  for  while  you  may  regret  taking  the  splint  off 
too  soon  you  will  never  regret  leaving  it  on  too  long.  The  adjust- 
ment of  braces  and  immobilizing  apparatus  and  the  period  of  time 
in  which  they  should  be  worn  should  be  left  to  the  judgment  of 
surgeons  with  special  orthopedic  experience. 

TREATMENT  OF  COMPLICATIONS. — (a)  Abscess  should  be  treated 

'  •      i:  '1 

conservatively.  •'"  Ifcis  well  to  remember  that  these  abscesses  under  the 
influence  of  rest  alone  are  sometimes  absorbed.  Hence,  when  abscess 
formation  threatens,  the  patient  should  be  placed  in  .the  recumbent 
position.  If  absorption  does  not  take  place,  aspirate,  remove  the  con- 
tents by  suction,  and  inject  a  five  per  cent,  emulsion  of  iodoform  and 
glycerin.  Any  further  operative  procedures  can  only  be  justified  by 
vital  necessity. 

(b)  Resection  of  the  Hip. — When  we  consider  the  excellent  re- 
sults obtained  by  conservative  treatment  it  is  doubtful  whether  a 
child  should  be  subjected  to  this  procedure,  especially  when  we  con- 
sider that  the  mortality  is  high  and  the  functional  results  unsatis- 
factory— the  interference  with  growth  causes  great  shortening  and 
deformity.     Besides  the  price  paid  does  not  insure  the  removal  of 
the  disease. 

As  a  rule  it  may  be  stated  that  resection  may  be  considered  after 
conservative  treatment  has  failed  and  where  conditions  of  necrosis, 
extensive  caries,  prolonged  suppuration,  and  intrapelvic  abscess 
make  recovery  impossible  without  operative  interference. 

(c)  Amputation  is  done  only  to  save  the  child's  life  after  con- 
servative treatment  to  save  the  limb  has  failed. 

CHAPTER  LXXVI 

FRACTURES  OF  THE  FEMUR 

FRACTURE  OF  THE  NECK  OF  THE  FEMUR 

Fracture  of  the  neck  of  the  femur  was  formerly  thought  to  be 
extremely  rare  in  children.  The  investigations  of  Whitman,  how- 
ever, have  shown  that  it  is  by  no  means  uncommon  and  until  quite 


FRACTURE    OF    THE    NECK    OF    THE    FEMUR       629 

recently  has  passed  unrecognized.  The  reason  for  this  is  quite  evi- 
dent when  we  consider  the  distinct  difference  in  the  clinical  picture 
presented  by  a  fracture  of  the  neck  of  the  femur  in  children  and 
that  of  a  similar  injury  in  old  age. 

In  old  age  a  slight  injury  is  followed  by  immediate  disability. 
In  childhood  a  severe  injury  is  followed  by  slight  disability.  It  is 
only  later  that  the  maximum  disability  occurs.  It  is  obvious  that 
such  an  injury  may  be  mistaken  for  a  sprain  or  contusion  of  the 
hip.  This  deceptive  symptomatology  is  explained  by  the  fact  that 
fracture  of  the  neck  of  the  femur  in  childhood  is  usually  of  the 
"green-stick"  variety;  hence  there  is  no  complete  and  immediate 
disability,  on  the  contrary  after  a  few  days  the  patient  is  able  to 
walk  with  slight  limp  and  discomfort.  After  several  months  or 


FIG.  250. — SHOWING  A.  FRACTURE  OF  THE  NECK  OF  THE  FEMUR;  AND  B.  RESTORATION  OF 
THE  NORMAL  ANGLE  BY  FORCIBLE  ABDUCTION.  (Whitman.) 

years,  however,  there  may  be  pronounced  disability  due  to  a  gradual 
bending  of  the  femoral  neck — "coxa  vara  traumatica/' 

Diagnosis. — When  a  child  has  received  a  severe  injury  to  the  hip 
careful  examination  should  be  made  in  order  that  a  fracture  of  the 
neck  of  the  femur  may  not  pass  unrecognized  and  untreated. 

In  case  of  a  "green-stick"  fracture  there  are  shortening  of  the 
thigh — one-half  to  three-quarters  of  an  inch — slight  outward  rota- 
tion, limitation  of  motion,  and  some  discomfort.  The  clinical  evi- 
dence should  be  confirmed  by  the  radiograph. 

Treatment. — As   soon    as   the   diagnosis    is   made   the   treatment 


630  FRACTURES  OF  THE  FEMUR 

should  be  after  the  method  of  Whitman — "The  patient  having  been 
anesthetized,  the  limb,  under  manual  traction,  should  by  gentle  force 
be  placed  in  the  attitude  of  full  abduction  and  extension,  thus  utiliz- 
ing the  fulcrum  of  the  upper  border  of  the  acetabulum  to  restore 
the  normal  angle  of  the  neck  (Fig.  250).  In  this  position  a  plaster 
bandage  reaching  from  the  axilla  to  the  toes  should  be  applied." 
(Fig.  251.)  After  six  weeks  a  traction  hip  splint  should  be  worn 


FIG.  251. — THE  LONG  SPICA  AS  APPLIED  FOR  THE  TREATMENT  OF  FRACTURE  OF  THE 
NECK  OF  THE  FEMUR.  (Whitman.) 

for  several  months  until  union  is  sufficiently  firm  to  eliminate  the 
dangers  of  a  subsequent  coxa  vara. 

FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR 

Pathology. — Fracture  of  the  shaft  of  the  femur  is  very  frequent 
in  children.  The  majority  are  oblique  fractures  of  the  shaft.  They 
are  caused  by  direct  or  indirect  violence  incurred  through  gym- 
nastics or  through  a  fall  from  a  great  height.  It  is  to  be  noted 
that  in  small  children  with  rickets  the  fracture  is  more  often  trans- 
verse than  spiral,  especially  as  the  fracture  approaches  the  lower 
end  of  the  femur  (Spitzy).  Subperiosteal  fracture  here  is  rarely 
found  since  the  pull  of  the  strong  muscle  masses  soon  causes  com- 
plete displacement.  In  fracture  of  the  upper  third  there  are  apt  to 
be  abduction  of  the  upper  and  adduction  of  the  lower  fragment.  In 


FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR   G31 

the  lower  third  displacement  is  usually  very  slight  except  in  the 
supracondylar  fractures,  where  the  action  of  the  gastrocnemius  pulls 
the  peripheral  fragment  back  into  the  popliteal  space  and  may  com- 
press the  artery  which  lies  close  to  the  bone. 

Diagnosis. — The  diagnosis  is  not  difficult;  the  evident  deformity, 
shortening,  displacement,  and  crepitus  confirm  the  suspicion. 

Treatment. — The  use  of  the  Bradford  frame  with  vertical  sus- 
pension of  the  injured  limb  is  by  far  the  most  satisfactory  method 
of  treatment. 

The  child  lies  upon  the  Bradford  frame,  to  which  the  shoulders 


FIG.  252. — VERTICAL  SUSPENSION  IN  FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR.  (Spitzy.) 

and  trunk  are  fixed  by  straps.  Adhesive  strips  are  applied  to  the 
legs  as  in  Buck's  extension,  the  limb  is  flexed  at  a  right  angle  to  the 
body,  and  extension  secured  by  weight  and  pulley  attached  to  some 
improvised  support  immediately  above  the  patient.  (The  support 
may  easily  be  constructed  of  barrel  hoops  secured  to  bed  or  peram- 
bulator [Fig.  252].)  The  extension  weight  should  be  heavy  enough 
to  just  lift  the  buttock  of  the  injured  side  off  the  mattress  and 
allow  the  opposite  buttock  to  come  in  full  contact  with  the  mattress. 
In  case  of  much  displacement  coaptation  splints  may  be  applied  to 
the  thigh  in  addition.  This  seemingly  awkward  position  is  well 


632  AFFECTIONS  OF  THE  KNEE 

borne  by  children  and  has  the  advantage  of  keeping  the  child  dry 
and  clean.  Frequent  inspection  is  necessary  to  avoid  decubitus  on 
account  of  the  tender  skin.  After  firm  union  is  secured  apply  a 
plaster  spica,  allow  the  patient  up,  put  a  high  shoe  upon  the  well 
foot,  and  let  him  get  about  with  crutches. 


CHAPTER  LXXVII 

AFFECTIONS    OF    THE    KNEE 

CONGENITAL  ABSENCE  OF  THE  PATELLA 

Congenital  absence  of  the  patella  is  usually  associated  with  other 
malformations  of  the  skeleton,  such  as  congenital  dislocation  of  the 
hip,  absence  of  the  fibula,  etc.  Absence  of  the  patella  without  other 
lesions  is  rare. 

The  knee  presents  a  flattened  appearance.  The  examining 
fingers  penetrate  into  the  depression  between  the  femur  and  tibia 
and  the  conformation  of  the  articular  elements  is  easily  outlined. 

In  some  cases  there  is  no  great  functional  disturbance,  in  others 
there  is  a  certain  amount  of  articular  instability  shown  by  the 
lateral  movements. 

Treatment. — The  treatment  will  depend  upon  the  amount  of 
functional  disability.  Orthopedic  apparatus  is  of  real  service  in 
appropriate  cases. 

In  "flail  knee"  an  arthrodesis  at  the  knee  joint  is  indicated. 

CONGENITAL  DISLOCATION   OF   THE   PATELLA 

Like  congenital  dislocation  of  the  hip  the  lesion  is  not  recog- 
nized until  the  child  begins  to  walk. 

The  patella  is  usually  displaced  outward  and  may  be  de- 
scribed as: 

(a)  Incomplete  dislocation;  the  patella  in  flexion  rests  in  front 


INJURY    OF    THE    TUBERCLE    OF    THE    TIBIA       G33 

of  the  external  condyle,  but  in  extension  it  returns  to  its  normal 
position. 

(b)  Intermittent  dislocation;  the  patella  is  displaced  while  bend- 
ing the  knee  and  returns  to  its  normal  position  in  extension. 

(c)  Permanent    dislocation;   the    patella    remains    permanently 
displaced  on  the  outer  surface  of  the  external  condyle.     It  has  been 
found  that  in  many  of  these  cases  there  is  a  diminution  in  the  size 
of  the  trochlear  surface  of  the  external  condyle.     In  inveterate  cases 
it  is  often  a  secondary  phenomenon  of  genu  valgum. 

Treatment  depends  upon  the  amount  of  functional  disability. 
In  the  majority  of  cases  it  will  be  sufficient  to  prescribe  an  elastic 
knee  cap. 

In  cases  with  notable  impairment  of  function  (instability, 
synovitis,  etc.)  operative  intervention  is  indicated.  Operative  inter- 
ference in  these  cases  is  extremely  difficult  and  delicate  since  it 
contemplates  entering  the  joint,  freeing  the  patella,  deepening  the 
intercondyloid  groove,  which  is  completely  filled  up,  and  plication 
of  the  capsule.  Or  the  line  of  traction  can  be  changed  by  detach- 
ing the  tuberosity  of  the  tibia  with  its  attached  ligamentum  patella? 
and  anchoring  it  by  sutures  further  inward. 


INJURY  OF  THE  TUBERCLE  OF  THE  TIBIA 

During  childhood  and  adolescence,  before  the  tubercle  is  united 
to  the  shaft,  a  sudden,  violent  action  of  the  quadriceps  extensor 
muscle  may  result  in  separation  of  the  tibial  tubercle.  Poland 
records  ten  cases,  all  occurring  in  athletic  boys  between  the  ages 
of  sixteen  and  eighteen. 

In  all  injuries  about  the  knee  resulting  from  sudden  strain  of 
the  quadriceps  extensor,  separation  of  the  tibial  tubercle  and  frac- 
ture of  the  patella  should  be  carefully  distinguished. 

It  should  be  remembered  that  fracture  of  the  patella  is  not  a 
lesion  of  childhood  and  is  very  rare  in  adolescence. 

In  separation  of  the  tibial  tubercle  there  are  swelling,  pain, 
tenderness,  apparent  enlargement  of  the  tubercle,  and  loss  of  func- 


634 


AFFECTIONS  OF  THE  KNEE 


tion.  Crepitus  may  be  obtained  by  pulling  the  fragment  downward 
(White). 

In  doubtful  cases  the  X-ray  will  furnish  conclusive  evidence. 

Treatment. — The  fragment  should  be  drawn  down  to  its  normal 
position  and  the  leg  fixed  in  an  extended  position  by  means  of  a 
plaster  bandage.  Complete  recovery  is  the  usual  result. 

GENU   VALGUM 


It  must  be  remembered  that  normally  the  axis  of  the  femur  and 
the  axis  of  the  tibia  do  not  form  a  straight  line,  but  a  line  broken 

at  the  level  of  the  knee  by  an  ob- 
tuse angle  open  externally.  The 
knee  therefore  naturally  inclines 
inward;  and  genu  valgnm  or 
"knock-knee"  is  only  an  exaggera- 
tion of  this  physiological  disposi- 
tion to  the  extent  of  a  deformity. 
(Fig.  253.) 

Age  of  Occurrence. — Genu  val- 
gum  is  found  at  two  distinct  peri- 
ods— in  young  children  and  in 
adolescents — and  between  these 
two  there  is  an  important  differ- 
ence. 

In  the  genu  valgum  of  young 
children  the  underlying  cause  is 
rickets  and  it  is  most  frequently 
manifest  between  the  first  and 
fifth  years.  It  is  usually  a 
bilateral  affection,  though  knock-knee  may  be  present  on  one  side 
and  bow  legs  on  the  other.  It  is  often  associated  with  other  char- 
acteristic rachitic  deformities.  It  is  obvious  that  when  the  child 
assumes  the  erect  posture  and  endeavors  to  maintain  its  equi- 
librium there  must  be  an  increased  demand  on  the  bony  tissue 
not  as  yet  completely  solidified.  Furthermore,  the  weakness 


FIG.  253. — GENU  VALGUM  OR  "KNOCK- 
KNEE".  (Estor.) 


GENU   VALGUM  635 

in  the  knee  is  associated  with  a  relaxation  of  the  muscles  and 
ligaments  of  the  foot;  hence  knock-knee  and  flat  foot  are  gener- 
ally associated.  As  a  result  these  children  try  to  compensate  for 
the  weakness  of  structure  by  strength  of  attitude;  hence  they  stand 
with  the  knees  braced  against  each  other  and  the  feet  far  apart ; 
finally  the  bone  yields  at  those  points  which  are  specially  subjected 
to  weight  and  where  there  is  a  natural  tendency  to  curvature.  The 
lesion  is  found  in  the  abnormal  obliquity  of  the  epiphyseal  lines  or 
marked  curvatures  in  the  lower  end  of  the  femur  or  upper  end  of 
the  tibia.  There  is  also  associated  with  it  a  relaxation  of  the  liga- 
mentous  structures  of  the  joint  which  permits  of  abnormal  joint 
movements. 

In  the  genu  valgum  of  adolescence  the  lesion  is  usually  uni- 
lateral and  well  defined.  Some  observers  believe  that  it  is  a  mani- 
festation of  late  rickets,  others  attribute  it  to  a  disproportionate  de- 
velopment of  the  two  condyles ;  physiological  activity  being  greater 
in  the  internal  condyle  than  in  the  external  condyle.  However,  the 
lesion  is  almost  constantly  found  in  the  internal  condyle  of  the 
femur.  It  is  only  in  very  pronounced  cases  that  there  is  a  curva- 
ture in  the  lower  end  of  the  diaphysis. 

Symptoms. — While  the  deformity  is  self-evident,  the  parents  are 
concerned  at  first  only  with  the  awkward  gait,  which  may  vary  from 
a  slight  limp  to  a  "waddling"  gait,  depending  on  the  extent  of  the 
deformity,  and  complaints  of  pain  in  the  knees  and  legs  after 
exercise. 

EXAMINATION. — The  preliminary  symptoms  will  suggest  a  thor- 
ough examination  of  the  naked  child,  both  standing  and  lying 
down.  Inspection  of  the  child  while  standing  reveals  the  deformity 
at  the  knee  by  the  fact  that  the  child  stands  with  the  knees  in  con- 
tact and  the  feet  some  distance  apart.  In  establishing  the  degree 
of  knock-knee  the  patient  should  be  lying  down  with  the  limbs  fully 
extended  and  the  two  knees  in  contact.  The  amount  of  separation 
between  the  two  internal  malleoli  measures  the  amount  of  deformity. 
The  deviation  is  corrected  when  the  two  internal  malleoli  can  be  put 
together  and  the  knees  touch. 

A  record  of  the  deformity  should  be  made  on  a  sheet  of  paper 


636  AFFECTIONS  OF  THE  KNEE 

placed  beneath,  reaching  from  the  ankle  to  above  the  knees,  the 
limbs  traced  with  pencil  and  the  distance  between  the  malleoli  noted 
in  inches.  A  comparison  of  these  records  gives  an  exact  idea  of 
the  progress  of  the  case. 

Passive  movements  of  the  knee  cause  no  pain.  It  will  be  found, 
however,  that  when  the  leg  is  flexed  on  the  thigh  the  deformity 
disappears — due  to  the  simple  anatomical  fact  that  when  the  thigh 
is  flexed  the  femur  rotates  outward  on  its  own  axis,  hence  the  ap- 
parent correction  of  the  deformity  and  the  importance  of  applying 
all  mechanical  treatment  with  the  leg  fully  extended. 

As  nature  always  tries  to  cure  a  curvature  by  a  counter  curva- 
ture, so  we  often  find  compensatory  deformities  such  as  flat  foot, 
an  equinovarus  position  of  the  foot,  lumbar  scoliosis,  etc. 

Prognosis. — Every  case  can  be  improved  by  treatment.  In  mild 
cases  hygienic  and  mechanical  treatment  will  be  efficacious;  in 
severe  cases  operation  will  improve. 

Treatment   in  young  children  should  embrace: 

1.  PROPHYLAXIS. — The  habit  of  carrying  the  child  about  on  the 
arm  of  the  nurse  should  be  discouraged.    In  children  with  soft  bones 
it  is  a  competent  cause  of  curvatures.     Infants  should  lie  on  their 
back  or  belly  and  be  wheeled  about. 

The  habit  of  encouraging  children  to  walk  by  offering  artificial 
support  is  to  be  condemned.  Children  pass  spontaneously  from  the 
crawling  to  the  walking  period  when  the  apparatus  of  locomotion  is 
prepared  for  its  additional  burden. 

Precocious  walking  is  responsible  for  much  precocious  deformity. 

2.  EXPECTANT  TREATMENT. — By  this  is  not  meant  the  expecta- 
tion of  a  spontaneous  cure  by  ignoring  the  condition.     It  implies 
rest,  constitutional  treatment,  massage,  and  passive  movements. 

In  rachitic  knock-knee  the  patient  should  be  kept  off  the  feet; 
sea  air,  sun  baths,  proper  diet,  and  antirachitic  treatment  are  the 
fundamentals.  The  legs  should  be  massaged  daily  and  the  de- 
formity gently  corrected  by  grasping  firmly  the  inner  condyle  and 
the  lower  part  of  the  extended  leg.  Only  such  force  should  be  used 
as  is  borne  with  comfort  by  the  child.  This  manipulation  should 
be  repeated  several  times  a  day. 


GENU   VALGUM 


637 


It  is  obvious  that  this  treatment  is  applicable  only  in  mild  cases 
and  under  conditions  where  the  social  status  permits  constant  super- 
vision. 

3.  MECHANICAL  TREATMENT. — The  principle  of  this  treatment 
is  to  establish  a  continuous  pull  on  the  knee  with  the  ultimate  aim 
of  changing  the  relations  of  the  femoral  condyle  by  causing  atrophy 
of  the  internal  condyle  and  enlargement  of  the  external  condyle. 
Thus  an  anatomical  cure  is  produced. 

Various  apparatus  have  been  devised  for  the  correction  of  knock- 
knee.  The  simplest  and  most  effective 
is  the  "knock-knee"  brace  of  Bradford 
and  Lovett.  (Fig.  254.)  It  consists 
of  "a  light  steel  rod  attached  below  to 
a  steel  sole  plate  and  joined  at  the 
ankle.  It  runs  up  the  outside  of  the 
leg  as  far  as  the  trochanter  and  then 
the  rod  is  bent  backward  and  upward, 
to  lie  against  the  upper  part  of  the  but- 
tock and  serve  as  an  arm  by  which  the 
leg  can  be  everted  or  inverted  if  the 
child  toes  in  or  out  in  walking. 

"The  knee  is  drawn  upon  by  a 
square  leather  pad  pulling  from  the 
shaft  opposite  the  knee.  The  upper 
ends  of  the  apparatus  should  be  buckled 
posteriorly  together  by  two  straps,  one 
connecting  the  tips  of  the  posterior  arms 
and  sometimes  another  may  be  needed, 

running  across  the  lower  abdomen,  connecting  the  shafts ;  by  length- 
ening and  shortening  these  straps  it  is  evident  that  any  desired  de- 
gree of  inversion  or  eversion  of  the  feet  may  be  produced." 
(Bradford  and  Lovett.)  It  is  obvious  that  mechanical  treatment 
is  efficacious  only  when  the  bones  are  soft  and  yielding,  otherwise 
such  treatment  only  leads  to  derangement  of  the  joint.  Hence, 
mechanical  treatment  is  indicated  before  the  fourth  or  fifth  year. 
Little  is  to  be  expected  from  it  after  this  age.  If  no  improvement 


FlQ.    254. "K  N  O  C  K  -K  N  E  E" 

BRACE  OF  BRADFORD  AND 
LOVETT.  (Keen's  Surgery.) 


638 


AFFECTIONS  OF  THE  KNEE 


is  secured  from  mechanical  treatment  after  a  trial  of  six  months — 
operation  should  be  considered. 

4.  OPERATIVE  TREATMENT. — (a)  Forcible  Correction  Under 
Ether  and  Application  of  Plaster  Cast. — This  method  of  treatment 
is  specially  applicable  to  young  children  whose  social  position  is 

such  that  mechanical  treatment  can- 
not be  effectively  applied.  Some  au- 
thors believe  that,  whatever  the  social 
position,  it  is  better  to  do  one  pro- 
cedure for  correcting,  rather  than 
months  of  splints. 

Forcible  correction  of  the  defor- 
mity may  be  accomplished  by  osteo- 
clasis — forcible  fracture  by  manual 
or  instrumental  means;  or  epiphy- 
seolysis — loosening  and  displacing 
the  lower  epiphysis  of  the  femur  by 
manual  pressure. 

It  is  obvious  that  in  both  these 
procedures  in  addition  to  the  inac- 
curacy there  is  considerable  derange- 
ment of  the  soft  parts  about  the 
knee — not  to  mention  ankylosis,  and 
paralysis  of  the  peroneal  nerve  which 
in  some  cases  have  remained  perma- 
nent. 

(b)  Osteotomy  (Partial  Division 
of  the  Bone  by  Chisel,  Completed  Di- 
vision by  Fracturing  the  Partly  Di- 
vided Bone). — MacEwen's  supra- 
condyloid  osteotomy  has  given  excellent  results.  It  consists  of  a  par- 
tial division  of  the  shaft  of  the  femur  just  above  the  internal  condyle, 
the  operation  being  completed  by  forcible  fracture.  (Fig.  255.) 

Method. — With  careful  antiseptic  preparation  of  field  of  opera- 
tion and  light  ether  anesthesia  the  patient  should  lie  on  his  side 
so  that  the  outer  surface  of  the  knee  rests  on  a  sand-bag. 


FIG.   255. — MACEWBN'S  SUPRACONDT- 
LOID  OSTEOTOMY.  (After  Jacobson.) 


GENU    VARUM  639 

"Point  of  election"  at  inner  side  of  thigh  one-half  inch  above 
the  adductor  tubercle  of  the  internal  condyle.  At  this  point  the 
skin  is  divided  just  enough  to  permit  the  osteotome  to  enter. 
By  gently  tapping  with  a  mallet  the  osteotome  divides  the  bone 
from  within  out  until  three-fourths  of  the  bone  has  thus  been  cut 
through.  The  remaining  portion  is  fractured  by  gentle  pressure. 
The  leg  is  now  placed  in  a  corrected  position,  the  skin  incision 
dressed  with  aseptic  gauze,  and  the  limb  immobilized  in  a  plaster 
cast.  At  the  end  of  four  weeks  the  cast  is  removed,  and  in  six 
weeks  the  patient  is  permitted  to  stand  on  the  leg. 


GENU  VARUM 

Genu  varum  (bow  legs)  is  the  opposite  deformity  to  genu 
valgum.  The  leg  and  thigh  form  an  angle  or  curve  internally,  the 
apex  of  the  angle  or  curve  being  at  the  knee.  The  deformity  is 
characterized  by  the  knees  being  more  or  less  separated  and  the 
malleoli  in  contact.  It  is  usually  bilateral,  sometimes  accompanied 
by  genu  valgum  of  the  opposite  side,  and  is  an  affection  of  early 
childhood  (Fig.  256). 

Etiology. — The  habit  of  carrying  a  child  on  the  arm  of  a  nurse 
always  on  the  same  side  is  a  frequent  cause  of  curvature  of  the 
lower  extremities.  Some  children  are  born  with  an  exaggeration 
of  the  natural  curve  of  the  tibia  and  exhibit  bow  legs  before  they 
attempt  to  walk. 

The  principal  cause  of  genu  varum,  however,  is  nearly  always 
rickets  and  hence  it  usually  appears  when  the  child  begins  to  walk. 
The  soft  bones  are  unequal  to  the  superimposed  weight  and  yield 
in  the  line  of  least  resistance.  The  deformity  is  usually  bilateral. 

The  site  of  the  lesion  varies.  As  a  rule  there  is  bowing  of  both 
femur  and  tibia ;  in  other  cases  the  femur  is  normal  and  the  bow- 
ing is  in  the  upper  or  lower  third  of  the  tibia.  The  fibula  follows 
the  lead  of  the  tibia  and  bows  with  it.  It  is  not  rare  to  find  asso- 
ciated with  genu  varum  other  stigmata  of  rickets. 

Symptoms. — First:  General  symptoms  of  rickets.     Second:  The 


640 


AFFECTIONS  OF  THE  KNEE 


deformity  is   apparent.     When  the  feet   are  brought  together   the 
knees  are  separated,  and  the  Germans  have  aptly  called  it  "0-leg." 
The  gait  is  modified  so  that  the  child  walks  with  a  waddle,  and 
in  severe  cases  resembles  that  of  congenital  dislocation. 

EXAMINATION. — Thorough  examination  of  the  naked  child,  both 
standing  and  lying  down.  Determine  the  exact  site  of  the  deformity, 
whether  in  femur  or  tibia.  Bring  the  insides  of  the  knees  together 

by  crossing  the  legs  and 
note  whether  the  thighs  are 
parallel  or  not.  For  pur- 
poses of  record  make  trac- 
ings of  the  deformity  by 
placing  the  child  on  the 
back  upon  a  sheet  of  paper 
and  outline  the  legs  with 
pencil. 

Prognosis. — Every  case 
can  be  improved  by  treat- 
ment. In  mild  cases  hy- 
gienic and  mechanical  treat- 
ment will  be  efficacious;  in 
severe  cases  operation  will 
improve. 

Treatment.  — The  treat- 
ment is  similar  to  that  of 
knoek-knee.  All  the  meas- 
ures recommended  for  rick- 
ets are  applicable  here  (see 
p.  128). 

1.  PROPHYLAXIS. — Many  curvatures  of  the  lower  extremities 
can  be  avoided  by: 

(a)  Forbidding  the  child  to  be  carried  about  on  the  arm  of  a 
nurse.     Soft  bones  yield  to  continued  pressure. 

(b)  Avoid  using  very  thick  diapers. 

(c)  Do  not  encourage  the  child  to  walk  too  soon.     Precocious 
walkijig  is  responsible  for  much  precocious  deformity. 


FIG.  256. — BILATERAL  GENTJVARUM.  (Spitzy.) 


GENU   VAEUM 


641 


2.  EXPECTANT   TREATMENT. — For   children  under   three   years 
old  no  mechanical  treatment  is  necessary.     When  any  tendency  to 
this  deformity  is  noted  use  massage  and  manual  pressure.     Several 
times  a  day  the  child  can  sit  with  the  ankles  together  and  gentle 
pressure  be  exerted  upon  the  legs  at  the  point  of  greatest  curvature. 
Much  benefit  may  be  obtained  from  the  expectant  treatment  since 
bow  legs  show  a  greater  tendency  toward   spontaneous   cure  than 
knock-knee 

3.  MECHANICAL  TREATMENT. — The  principle  of  this  treatment 

is  to  establish  a  continuous  in- 
ward pressure  by  the  application 
of  braces  to  the  inner  side  of  the 
leg.  Various  apparatus  have  been 
devised,  but  the  simplest  and 
most  effective  is  the  bow-leg 
brace  of  Bradford  and  Lovett 
(Fig.  25 T),  which  consists  of  "a 
light  steel  upright  which  is  at- 
tached below  to  the  sole  plate  of 
the  shoe.  It  runs  up  nearly  to 
the  origin  of  the  adductor  mus- 
cles, but  it  must  fall  a  little 
short  of  them  or  it  will  excori- 
ate the  skin  in  walking.  The 
upright  is  then  bent  forward  and 
upward,  and  curved  to  fit  into 
the  groin  and  come  up  as  far  as 
the  posterior  part  of  the  dorsum 
of  the  ilium.  In  this  way  a 
lever  is  provided  in  which  to  evert  the  feet  to  any  extent  by  alter- 
ing the  curve  of  their  arms  and  strapping  them  together  behind. 
Pads  for  the  outsides  of  the  legs  are  made  of  leather  and  buckled 
by  two  or  three  straps  to  the  upright,  opposite  the  greatest  con- 
vexity of  the  curve.  Where  the  curve  is  wholly  in  the  tibia  and 
the  child  does  not  'toe-in'  it  is  sufficient  to  carry  the  upright  just 
above  the  knee,  and  to  end  it  in  the  semi-circular  pad  plate  which 


FIG.  257. — BOW-LEG  BRACE  OF  BRADFORD 
AND  LOVETT.   (Keen's  Surgery.) 


642 

is  applied  against  the  inner  part  of  the  thigh."  (Bradford  and 
Lovett.) 

It  is  obvious  that  mechanical  treatment  is  efficacious  only  when 
the  bones  are  soft  and  yielding,  hence  it  is  indicated  before  the 
fourth  or  fifth  year.  If  no  improvement  is  secured  from  mechanical 
treatment  after  a  trial  of  six  months,  or  the  child's  social  position 
precludes  proper  care  and  attention,  operation  should  be  considered. 

4.  OPERATIVE  TREATMENT. — (a)  Forcible  Correction  Under 
Ether  and  Application  of  Plaster  Cast. — This  method  involves  frac- 
ture of  the  deformed  bone  either  manually  or  by  the  aid  of 
mechanical  appliances  (osteoclast). 

By  placing  the  limb  over  a  sand-bag  and  exerting  sudden  manual 
pressure  a  green-stick  fracture  is  produced  which  at  once  permits 
the  deformity  to  be  corrected;  or  a  more  precise  method  is  to  pro- 
duce the  fracture  by  means  of  an  osteoclast. 

After  a  corrected  position  has  been  secured  a  plaster  cast  should 
be  applied,  extending  from  the  toes  to  the  hip.  At  the  end  of  four 
weeks  the  cast  is  removed  and  in  six  weeks  the  patient  is  permitted 
to  stand  on  the  leg. 

(b)  Osteotomy  is  the  procedure  of  choice  in  sharp  curves  near 
the  ankle  or  knee,  and  in  all  cases  of  anterior  curvature  of  the  tibia. 

The  bone  is  divided  at  the  point  of  greatest  deformity  and  a 
linear  osteotomy  is  to  be  preferred  to  the  removal  of  a  wedge  which 
shortens  the  leg  (Lovett).  The  technique  of  this  operation  is  de- 
scribed on  p.  638. 

GENU   RECURVATUM 

This  is  a  deformity  characterized  by  a  hyperextension  of  the 
knees,  so  that  the  leg  forms  with  the  thigh  a  curve  with  an  anterior 
concavity.  Sometimes  the  deformity  is  so  accentuated  that  the 
lower  extremity  of  the  femur  forms  a  prominence  in  the  popliteal 
space ;  or  the  leg  may  form  an  acute  angle  with  the  anterior  surface 
of  the  thigh.  This  deformity  may  be  congenital  or  acquired.  It  is 
usually  secondary  to: 

(a)   Infantile    paralysis    where    the    loss    of    muscular    control 


TUBEKCULOSIS    OF    THE    KNEE  643 

places  the  knee  in  hyperextension  and  overstretches  the  posterior 
ligaments. 

(b)  Tuberculous  disease  of  the  joint  where  the  ligaments  are 
destroyed. 

(c)  Hip-joint  disease  treated  by  traction. 

(d)  Traumatism. 

Treatment   by  means   of   a   brace   with   a   stop- joint  to   prevent 
hyperextension. 

TUBERCULOSIS   OF   THE   KNEE 

(Tumor  Albus,  White  Swelling) 

Tuberculous  disease  of  the  knee-joint  is  quite  frequent,  follow- 
ing in  the  order  of  frequency  after  Pott's  disease  and  hip-disease. 
Pathology. — The  pathology  is  that  of  tuberculous  joint  disease 
in  general  (see  Tuberculosis  of  the  Joints,  p.  205).  The  exciting 
cause  is  often  attributed  to  slight  traumatism,  contusions,  or 
wrenching  of  the  joint.  It  appears  mostly  in  the  osseous  form,  the 
foci  being  located  in  the  condyles  of  the  femur,  the  head  of  the  tibia, 
or  in  the  patella ;  probably  the  head  of  the  tibia  is  most  frequently 
affected. 

The  usual  course  of  the  tuberculous  process  is  observed  in  the 
swollen  joint  distended  by  synovial  fluid  or  by  tuberculous  granula- 
tions. The  knee  assumes  its  biological  position — midflexion;  "pain 
position";  swelling  accentuated  by  the  action  of  the  muscles  gives 
the  joint  a  peculiar  spindle-shaped  appearance,  covered  with  tense, 
shiny,  waxy  skin,  from  which  it  derives  the  name  "white  swelling." 
Later  the  process  goes  on  to  caseation,  suppuration,  and  fistulization. 

As  the  knee  is  held  in  slight  flexion  the  action  of  the  strong 
flexors  overcomes  the  extensor,  and  there  result  a  backward  sub- 
luxation  and  outward  rotation  of  the  tibia.  It  is  evident  that  the 
end  results  of  treatment  depend  upon  the  amount  of  destruction 
in  the  joint  elements.  A  hydrops  may  permit  of  healing  without 
changes  in  the  joint  function,  but  the  granulating  and  abscess  forms 
leave  in  their  wake  a  stiff  knee  due  to  fibrous  or  bony  ankylosis. 


644  AFFECTIONS  OF  THE  KNEE 

Symptoms. — The  symptoms  vary  according  to  the  clinical  evo- 
lution of  the  disease,  and  as  in  all  tuberculous  processes  they  appear 
slowly,  insidiously,  but  persistently.  When  a  child  exhibits  after 
slight  injury  to  the  knee  persistent  stiffness  or  limp  with  slight 
flexion  and  muscular  rigidity  of  the  joint,  tuberculous  disease  should 
be  suspected.  The  pain  at  first  may  be  only  a  feeling  of  discomfort, 
worse  in  the  morning  and  wearing  off  during  the  day.  Its  reflex  ex- 
pression is  shown  in  the  limp,  the  muscular  rigidity,  and  the  effort 
of  the  child  to  protect  the  joint  from  motion.  Not  infrequently  are 
these  early  symptoms  misinterpreted  and  valuable  time  lost  by 
mistaking  a  tuberculous  joint  for  rheumatism. 

As  the  disease  advances  the  knee  assumes  a  position  of  flexion, 
the  position  of  greatest  comfort.  With  the  knee  in  fixed  flexion  the 
child  walks  only  on  the  toes  and  avoids  as  much  as  possible  the  dis- 
comfort of  weight-bearing.  The  swelling  about  the  knee  increases, 
the  muscles  of  the  thigh  and  calf  atrophy,  and  the  joint  becomes 
spindle-shaped.  As  time  goes  on  the  fixation  becomes  more  perma- 
nent and  results  in  a  vicious  attitude,  which  invites  backward  sub- 
luxation;  the  pain  increases  in  severity  and  is  expressed  in  night 
cries.  Disorganization  of  the  elements  of  the  joint  follows  with 
abscess  and  fistulization. 

Shortening  is  not  a  conspicuous  feature,  on  the  contrary  it  is  not 
uncommon  to  find  lengthening  of  the  affected  limb  due  to  congestion 
of  the  epiphyses. 

Diagnosis. — Early  diagnosis  lessens  subsequent  disability  and 
shortens  the  course  of  the  disease.  The  frequency  of  tuberculous 
joint  disease  in  children  should  lead  us  to  look  with  suspicion  upon 
every  case  of  swelling  of  the  knee  joint  with  intermittent  lameness. 
As  Willard  tersely  observes,  "The  great  producer  of  cripples  is  the 
practitioner  or  surgeon  who  carelessly  passes  over  a  limp  or  a  pain 
as  a  'habit'  or  as  rheumatism — the  burden  of  proof  in  chronic 
diseases  of  the  knee  in  a  child  should  always  rest  upon  the  non- 
tuberculous  side  of  the  question,  since  infinite  risks  are  involved  by 
delaying  proper  treatment." 

The  X-ray  is  a  valuable  aid  in  differentiating  the  chronic  types 
of  joint  disease  from  tuberculosis. 


TUBEECULOSIS    OF    THE    KNEE  G45 

The  von  Pirquet  tuberculin  test  is  specially  serviceable  in  small 
children. 

Prognosis.— As  in  all  joint  tuberculosis  the  prognosis  depends 
upon  early  diagnosis  and  efficient  treatment.  In  children  the  prog- 
nosis is  exceptionally  good  when  treatment  is  begun  early.  The 
duration  of  the  disease  is  from  one  to  three  years  and  recovery  is 
attended  with  varying  functional  disability. 

Treatment. — It  must  be  ever  kept  in  mind  that  it  is  not  merely 
a  diseased  joint  that  needs  treatment,  it  is  a  sick  child.  The 
diseased  joint  is  but  the  local  expression  of  a  general  condition. 
Hence,  GENERAL  TREATMENT  of  the  child  to  so  improve  the  tissues 
that  the  tubercle  bacilli  will  cease  to  thrive.  The  tissues  of  the 
patient  are  improved  by  proper  nutrition,  unlimited  sunshine,  and 
fresh  air.  The  use  of  tuberculin  has  been  followed  by  excellent 
results  (see  Technique,  p.  201). 

LOCALLY  the  treatment  is  limited  to  the  most  conservative 
measures,  for  we  are  dealing  here  with  an  epiphyseal  center  that 
largely  contributes  to  the  growth  of  the  extremity.  The  whole  aim 
of  local  treatment  is  to  secure  physiological  rest  in  a  good  position; 
correction  of  the  vicious  attitude,  and  immobilization  of  the  articu- 
lation. 

The  blood  supply  to  the  diseased  joint  should  be  increased  by 
producing  artificial  chronic  congestion  after  the  method  of  Bier 
(see  Joint  Tuberculosis,  p.  207). 

In  the  acutely  painful  stage  the  patient  should  be  treated  in 
the  recumbent  position  with  the  joint  immobilized  and  with  traction 
in  the  line  of  deformity.  Forcible  correction  of  the  deformity  should 
never  be  attempted,  since  damage  to  the  popliteal  vessels  may  result 
in  gangrene. 

After  the  deformity  has  been  corrected  the  joint  is  immobilized 
by  a  plaster  cast  reaching  from  the  malleoli  to  the  adductor  tendons, 
a  high  shoe  is  placed  on  the  sound  leg,  and  the  patient  goes  about  on 
crutches,  or  the  Thomas  knee  splint  may  be  used.  It  consists  of  a 
leather-covered  perineal  ring,  two  steel  uprights  attached  to  the  ring 
above  and  joined  below  by  a  rubber-shod  steel  shoe  piece  which 
extends  two  inches  below  the  sole  of  the  foot.  Broad  leather  straps 


646  THE  TIBIA  AND  FIBULA 

above  and  below  the  knee  hold  the  appliance  in  place.  The  sole  of 
the  shoe  of  the  opposite  side  is  built  up  to  equalize  the  length  of  the 
limbs,  and  crutches  may  be  used,  though  they  are  not  necessary. 

When  symptoms  of  pain  and  muscular  spasm  have  subsided  the 
fixation  apparatus  may  be  gradually  withdrawn.  Any  return  of 
symptoms  is  an  indication  to  reapply  the  apparatus. 

Abscess  formation  should  be  treated  by  aspiration,  removal  of 
contents  by  suction,  and  injection  of  a  five  per  cent,  emulsion  of 
iodoform  and  glycerin. 

Operative  treatment  in  children,  except  for  abscess  or  deformity 
(angular  ankylosis),  is  not  to  be  considered.  The  only  rational 
procedure  is  persevering  conservative  treatment  to  save  the  limb, 
amputation  to  save  life. 


CHAPTER  LXXVIII 

THE    TIBIA    AND    FIBULA 

RACHITIC  CURVATURES  OF  THE  LEG 

These  are  among  the  most  frequent  manifestations  of  rickets 
during  the  first  three  years,  and  require  most  frequently  among 
allied  deformities  surgical  interference. 

These  curvatures  are  always  more  prominent  in  the  tibia  be- 
cause it  is  the  weight  carrier.  They  are  generally  bilateral ;  when 
unilateral  the  left  leg  is  usually  affected. 

Pathology. — There  are  a  great  variety  of  these  deformities,  yet 
it  will  be  noted  they  all  follow  a  certain  type.  They  are  all  the 
expression  of  an  exaggeration  of  the  normal  physiological  curves, 
plus  the  greater  pull  of  the  biologically  older  groups  of  muscles — 
muscular  balance  depends  upon  normal  bone — softened  bone  yields 
to  the  stronger  muscular  pull. 

Note  in  one  of  the  most  common  types — anterior  curvature  of  the 
leg — the  deformity  is  at  the  weakest  point  at  the  junction  of  the 
lower  and  middle  thirds  (Fig.  258).  The  bony  tissue  adapts  itself 


CONGENITAL  ABSENCE  OF  THE  FIBULA 


647 


to  the  changed  conditions — on  the  weighted,  concave  side  it  becomes 
stronger  and  more  compact,  on  the  opposite  side  it  is  less  dense. 
The  bone  is  further  modified  from  the  triangular  to  the  flattened 
form  ("saber  shin").  The  role  of  the  muscles  is  shown  by  the 
tense  condition  of  the  tendo  achilles,  which  bridges  the  curvature 
like  the  tightened  string  of  a  bow. 

The  deformity   is   accompanied   by  functional   troubles   due   to 
relaxation  of  the  neighboring  joints,  and  deviations 
of  the  foot,  hence  the  gait  is  uncertain  and  the  child 
frequently  falls. 

Treatment. — PROPHYLAXIS  (see  p.  128). — Em- 
ploy antirachitic  measures — sunshine,  sea  air,  and 
proper  diet  are  the  essentials. 

No  weight  bearing  on  the  leg. 

If  the  deformity  still  increases  it  may  be  neces- 
sary to  use  orthopedic  apparatus  to  remove  weight 
from  the  leg.  No  operative  interference  until 
the  fifth  year — until  the  rachitis  is  cured. 

OPERATION. — At  the  proper  time  operation  is 
always  to  be  preferred  to  the  use  of  apparatus,  for 
its  use  always  implies  an  atrophic  influence  on  the 
limb.  A  linear  osteotomy  should  be  done  at  the 
point  of  greatest  curvature,  and  the  corrected  posi- 
tion maintained  by  a  plaster  cast  for  six  weeks. 

The  role  of  the  tendo  achilles  must  not  be  over- 
looked in  correcting  curvatures  of  the  leg.     It  plays 
an  important  part  in  their  production  and  should 
be  divided  subcutaneously  to  facilitate  correction  and  avoid  recur- 
rence. 


FIG.  258.— RA- 
CHITIC  CURVA- 
TURES OF  THE 
BONES  OF  THE 
LEG.  (Estor.) 


CONGENITAL  ABSENCE  OF  THE  FIBULA 


Congenital  absence  of  the  fibula  is  much  more  frequent  than 
that  of  the  tibia.     The  fibula  may  be  entirely  absent,  or  there  may 


648  THE  TIBIA  A>O)  FIBULA 

be  a  remaining  fragment  of  the  upper*  or  lower  part  of  the  bone — 
it  is  usually  the  lower  part  that  is  wanting. 

Pathology. — The  extremity  on  the  side  of  the  absent  fibula  is 
atrophied  and  shortened,  but  it  is  specially  accentuated  in  the  leg. 
The  shortening  is  the  result  of  an  angular  deformity  of  the  tibia 
at  the  junction  of  the  middle  and  lower  thirds  which  usually  curves 
forward  and  inward.  Quite  frequently  on  the  skin  over  the  angular 
prominence  is  found  a  cicatrix  more  or  less  depressed. 

In  most  of  the  cases  there  is  an  absence  of  one  or  more  of  the 
toes  on  the  fibular  side  of  the  foot,  while  there  are  often  other  mal- 
formations in  other  parts  of  the  body  associated  with  this  deformity. 

The  curvature  in  the  tibia  and  the  absence  of  the  external  mal- 
leolus  cause  the  foot  to  be  thrown  into  a  valgus  position,  while  the 
contraction  of  the  tendo  achilles  draws  the  heel  up  and  causes  the 
foot  to  assume  a  position  of  equinovalgus. 

Volkman's  deformity,  which  has  been  described  as  a  congenital 
deformity  of  the  tibiotarsal  joint,  in  which  the  whole  foot  is  thrown 
outward,  is  probably  the  result  of  a  congenital  absence  of  the  lower 
portion  of  the  fibula.  The  cause  of  this  arrest  of  development  can 
only  be  conjectured.  It  may  be  due  to  amniotic  compression,  or  to 
obscure  lesions  in  early  embryological  development. 

Diagnosis. — The  diagnosis  of  this  lesion  is  not  difficult  and  is 
promptly  confirmed  by  the  X-ray.  ^ 

Treatment. — There  are  two  evident  indications  for  treatment: 
(a)  the  curvature  of  the  tibia;  (b)  the  equinovalgus  deviation  of 
the  foot.  It  is  well  to  delay  treatment  until  the  age  of  two,  and  at 
that  time  proceed  to  straighten  the  tibia  by  a  cuneiform  osteotomy. 
It  is  well  to  note  that  the  position  of  the  foot  cannot  be  corrected 
by  the  usual  tenotomy  and  over-correction  for  equinovalgus  devia- 
tion since  the  absence  of  the  external  malleolus  only  invites  a 
recurrence. 

In  these  cases  it  will  be  necessary  to  divide  the  structures  which 
mold  the  foot  in  its  vicious  position  and  permanently  unite  the  foot 
and  leg  by  means  of  an  arthrodesis  of  the  tibiotarsal  joint.  Kirmis- 
son  remarks  that  in  some  cases  the  atrophy  is  so  great  that  we  are 
justified  in  amputating  the  limb. 


CONGENITAL   ABSENCE    OF    THE    TIBIA 


64i> 


CONGENITAL   ABSENCE   OF   THE   TIBIA 

Pathology. — Congenital  absence  of  the  tibia  is  much  rarer  than 
congenital  absence  of  the  fibula.  It  may  be  partial  or  complete,  uni- 
lateral or  bilateral  (Fig.  259).  Complete  absence  is  usually  accom- 
panied by  a  malformation  of 
the  condyles  of  the  femur 
which  appear  to  be  bifurcated 
and  the  head  of  the  fibula  ar- 
ticulates with  the  external  bi- 
furcation. 

The  crucial  ligaments  are 
absent  and  most  observers  re- 
port absence  of  the  patella, 
though  Kirmisson  believes 
that  it  is  usually  present  but 
not  recognized  because  it  is 
concealed  in  the  abnormally 
deep  hollow  between  the  con- 
dyles. The  fibula,  which  is 
considerably  hypertrophied, 
presents  a  decided  curvature 
directed  backward  and  out- 
ward. 

In  partial  absence  of  the 
tibia  the  upper  extremity 

forms     a     normal     articulation  FIG.  259.— CONGENITAL  ABSENCE^  THE  TIBIA. 

with  the  femur,  but  the  rem-  (Hoffa.) 

nant  of  bone  becomes  attenuated  and  terminates  in  a  sharp  point 
more  or  less  prominent  beneath  the  skin;  over  this  point  is  usually 
found  a  cicatricial  depression  similar  to  that  found  in  congenital  ab- 
sence of  other  bones.  The  whole  extremity  is  markedly  atrophied 
and  shortened,  and  there  are  usually  evidences  of  malformation  in 
other  parts  of  the  body,  absence  of  one  or  more  toes,  etc. 

As  a  result  of  this  malformation  we  find  two  characteristic  de- 


650  DEFORMITIES  OF  THE  FOOT 

formities:  (a)  the  leg  is  permanently  flexed  on  the  thigh;   (b)  the 
foot  is  in  a  position  of  extreme  varus  or  equinovarus. 

Prognosis. — The  prognosis  of  these  cases  is  not  encouraging.  The 
atrophy,  shortening,  and  vicious  position  only  increase  as  time 
goes  on. 

Treatment. — Many  of  these  cases  are  beyond  constructive  surgery 
and  require  amputation.  If  the  limb  is  sufficiently  developed  and 
the  fibula  hypertrophied  enough  to  support  the  weight  of  the  body 
constructive  surgery  promises  surprising  results. 

The  fibula  supplies  the  place  of  the  missing  tibia  by  transplant- 
ing the  head  of  the  fibula  into  the  intercondylar  notch  of  the  femur. 
The  foot  is  straightened  and  fixed  in  good  position  by  an  arthrodesis 
at  the  ankle  joint.  With  the  aid  of  prosthetic  apparatus  this  pro- 
cedure has  given  some  excellent  results. 

In  a  case  operated  by  Meyer  for  congenital  absence  of  the  tibia 
by  transplanting  the  head  of  the  fibula  and  doing  an  arthrodesis  at 
the  ankle  joint — the  shortening  from  the  anterior  superior  spine  to 
the  ball  of  the  foot  where  the  weight  is  borne  measures  two  inches, 
of  which  three-quarters  is  in  the  femur.  The  right  affected  calf  is 
three-quarters  of  an  inch  smaller  than  the  left.  The  foot  is  fixed  at 
135°.  There  are  no  hyperextension  and  no  rotation  possible  at  the 
knee.  The  boy  can  extend  his  leg  to  165°  strongly,  and  flex  it  to 
90°.  The  ankylosis  at  the  ankle  is  firm. 

These  cases  should  be  operated  upon  from  the  second  to  the 
fourth  year. 

CHAPTER  LXXIX 

DEFORMITIES    OF    THE    FOOT 

CLUB   FOOT 

Club  foot  is  a  term  popularly  applied  to  a  vicious  attitude  of 
the  foot  in  relation  to  the  leg.  More  specifically  it  is  a  deformity 
of  the  foot  in  which  the  sole  is  inverted,  the  heel  elevated,  and  the 
toe  turned  inward  (talipes  equinovarus).  The  foot  is  rolled  inward 


CLUB    FOOT 


651 


so  that  the  inner  surface  of  the  foot  looks  up,  the  outer  surface  is 
in  contact  with  the  ground,  so  that  the  patient  walks  on  the  outer 
side  and,  in  severe  cases,  on  the  dorsum  of  the  foot  (Fig.  2 GO). 

It  is  one  of  the  commonest  of  congenital  deformities,  occurs 
more  frequently  in  boys,  and  usually  affects  both  sides. 

Club  foot  may  be  either  congenital  or  acquired  as  the  result  of 
infantile  paralysis,  cicatrices,  or  injury. 


FIG.  260.— CLUB  FOOT. 

Note  that  the  foot  is  rolled  inward  so  that  the  inner  surface  of  the  foot  is  directed  upward. 

(Estor.) 


CONGENITAL    CLUB    FOOT 

Etiology.  —  The  etiology  of  this  deformity  is  variously  explained 
as  the  result  of  vicious  attitudes  during  intrauterine  life;  as  the 
result  of  faulty  development  of  the  foot,  etc. 

We  know  that  in  utero  the  feet  are  placed  against  each  other  by 
their  soles  and  in  this  supinated  position  most  children  are  born. 
The  extreme  of  this  position  would  give  club  foot  (Fig.  261).  Fur- 
thermore, heredity  seems  to  play  some  part  as  a  predisposing  factor, 
since  the  deformity  has  been  noted  in  the  parents  and  several  chil- 
dren of  the  same  family,  while  some  authors  have  found  club  foot 


E   Olr 


V    l>  I    I"*  I     (i   U  V- 


652 


DEFORMITIES  OF  THE  FOOT 


much  more  frequent  in  children  born  of  consanguineous  marriages 
than  among  others.  . 

We  know  that  the  deformity  occurs  in  company  with  other  de- 
fects, such  as  hydrocephalus  and  spina  bifida,  and  that  the  specific 
cause  of  these  malformations  is  as  yet  unknown. 

Pathological  Anatomy. — Fixation  of  the  foot  causes  a  correspond- 
ing change  in  the  bony  framework  and  the  fascia,  while  the  muscles 
adapt  themselves  to  the  changed  function.  Monod's  classification  is 
excellent  since  it  rationally  explains  the  three  distinct  pathological 
changes  in  the  progress  of  club  foot  in  the  order  of  their  develop- 
ment. This  author  divides  the  subject  into: 


FIG.  261. — CONGENITAL  CLUB  FOOT. 

(1)  MUSCULAR  CLUB  FOOT. — Here  the  vicious  attitude  is  main- 
tained by  the  retraction,  shortening,  and  tonic  action  of  the  muscles 
in  adapting  themselves  to  the  abnormal  direction  and  the  altered 
function.     This  shortening  is  most  marked  in  the  tibialis  anticus, 
the  tibialis  posticus,  and  the  gastrocnemius  as  shown  in  the  tension 
of  the  tendo  achilles.     The  course  of  the  tendons  is  more  or  less  modi- 
fied by  being  carried  further  inward,  as  for  example  the  common 
extensor  of  the  toes  and  the  extensor  proprius  hallucis.     This  is  the 
variety  of  club  foot  most  frequently  found  at  birth. 

(2)  LIGAMENTOUS  CLUB  FOOT. — This  is  more  complicated  than 
the  former,  since  to  muscular  contraction  is  added  ligamentous  con- 

5 .  J5  3  J , 


CLUB    FOOT  653 

traction.  The  contraction  is  specially  observed  in  the  plantar  liga- 
ments and  fascia  and  the  internal  lateral  ligament.  The  ligaments 
on  the  inner,  concave  side  are  all  shortened,  on  the  outer,  convex  side 
they  are  lengthened. 

(3)  OSSEOUS  CLUB  FOOT. — To  muscular  and  ligamentous  con- 
traction are  added  bony  deformities.  Hence  osseous  club  foot  does 
not  usually  appear  until  a  certain  time  after  birth.  It  will  be  seen 
that  bony  changes  are  brought  about  by  continued  pressure  in  an 
abnormal  direction.  Hence  the  tendency  of  the  deformity  is  obvious ; 
on  the  inner  or  concave  side  the  bones  are  pressed  together,  their 
volume  diminished,  and  their  tissues  condensed. 

On^he  outer  or  convex  side  the  bones  appear  enlarged  and  rare- 
fied. !Not  only  are  the  bones  distorted,  but  they  are  dislocated,  the 
normal  articular  surfaces  are  gradually  obliterated,  and  new  joint 
relations  formed. 

In  a  structure  like  the  foot,  combining  unusual  strength  and 
mobility,  such  a  deformity  as  club  foot  must  modify  all  the  bones  of 
the  tarsus,  yet  a  glance  at  the  normal  anatomical  relations  will 
demonstrate  that  the  astragulus — the  bony  link  that  connects  leg  and 
foot — must  be  the  center  of  the  deforming  influences. 

In  this  connection  we  note  that  the  astragulus  is  sublaxated  for- 
ward, its  posterior  part  articulates  with  the  tibia,  its  anterior  part 
is  enlarged,  cannot  be  embraced  „  by  the  tibiofibular  arch,  and  pro- 
jects beneath  the  skin. 

The  head  of  the  astragulus  is  atrophied  and  falls  inward,  the 
neck  is  lengthened,  and  the  head  bent  inward  so  that  the 
articular  surface  looks  inward  instead  of  forward.  The  os  calcis  is 
pulled  upward  by  the  tendo  achilles  so  that  it  approaches  a  vertical 
position.  It  undergoes  an  in-curving  so  that  the  concavity  of  its 
internal  surface  is  exaggerated  and  there  is  produced  a  correspond- 
ing convexity  of  its  external  surface. 

Where  the  deformity  exists  for  some  time  the  cartilaginous 
coverings  disappear  from  non-use  and  obstructions  are  formed 
which  make  return  to  the  normal  position  impossible.  The  other 
bones  of  the  tarsus  undergo  some  modifications,  but  they  are  not 
such  as  to  present  important  obstacles  to  reduction. 


654  DEFORMITIES  OF  THE  FOOT 

Thus  it  will  be  seen  that  to  a  primary  positional  defect  are  added 
complicated  pathological  changes  involving  muscles,  ligaments, 
fascia,  and  bone,  a  proper  appreciation  of  which  is  essential  before 
any  line  of  treatment  can  be  rationally  instituted. 

Symptoms. — In  addition  to  the  obvious  deformity  there  &re  great 
awkwardness  and  unsteadiness  in  walking — as  the  child  walks  on 
the  outer  edge  of  the  foot  and  the  "toeing  in"  is  pronounced,  one 
foot  must  be  lifted  over  the  other  as  the  step  is  taken.  As  the 
weight  is  borne  on  the  outer  edge  of  the  foot  pressure  bursse  and 
callosities  are  soon  developed. 

There  can  be  no  difficulty  in  diagnosing  congenital  club  foot. 

Prognosis.- — A  club  foot  untreated  never  tends  toward  spon- 
taneous cure,  but  toward  obstinate  malformation.  Under  modern 
treatment  a  cure  may  be  expected  in  children,  and  an  improvement 
promised  in  adult  cases. 

Treatment. — Whatever  procedure  is  chosen  it  must  be  clearly 
understood  that  there  are  two  distinct  deformities  to  be  corrected : 
(a)  correction  of  the  varus  position;  (b)  correction  of  the  equinus 
position,  and  the  deformity  should  receive  attention  in  the  order 
given.  While  the  methods  of  correction  vary,  the  purpose  is  the 
same:  reduction  of  the  deformity  and  retention  in  the  corrected 
position  until  the  cure  is  permanent. 

MECHANICAL  TREATMENT. —  (1)  The  treatment  of  congenital 
club  foot  of  the  new-born  should  be  begun  as  early  as  possible.  Just 
as  soon  as  the  child's  nutritional  status  is  established — at  the  end  of 
the  second  or  third  week — begin  manipulation  and  massage.  It 
must  be  remembered  that  the  foot  grows  rapidly  during  the  first 
months  of  life  and  if  the  growth  can  be  directed  in  a  normal  direc- 
tion during  this  period  much  can  be  accomplished  in  the  way  of 
correction.  As  Willard  observes,  every  case  of  club  foot  could  be 
cured  with  good  functional  motion  if  the  member  could  be  held  in 
the  corrected  position  by  a  human  hand  for  six  months. 

This  treatment  can  be  carried  out  by  an  intelligent  nurse  under 
the  direction  of  the  physician.  She  should  be  instructed  to  gently 
manipulate  the  foot  several  times  a  day  by  unrolling  it  and  hold- 
ing it  in  a  corrected  position  as  far  as  the  comfort  of  the  child  will 


CLUB    FOOT  655 

permit;  with  this  should  be  combined  massage  of  the  weakened 
muscles. 

When  the  contracted  muscles  and  ligaments  have  been  suffi- 
ciently stretched  so  that  the  foot  is  easily  held  in  the  corrected  posi- 
tion it  may  be  retained  by  a  light  plaster-of-paris  cast  reaching 
above  the  knee  and  renewed  every  two  or  three  weeks. 

This  treatment  persistently  followed  will  succeed  in  many  cases 
in  so  reducing  the  deformity  that  the  child  will  be  able  to  place  the 
sole  squarely  on  the  floor  when  it  begins  to  walk. 

Walking  on  a  deformed  foot  must  not  be  permitted,  since  by 
this  means  a  moderate  deformity  will  be  converted  into  an  in- 
veterate one. 

(2)  If  persistent  massage  gives  no  results  at  the  end  of  five 
months,  or  if  the  case  is  a  child  of  five  months  who  has  not  been 
previously  treated — forcible  straightening  under  ether  is  indicated 
to  place  the  foot  at  once  in  a  normal  position  so  that  as  the  child 
walks  he  becomes  an  active  agent  in  the  corrective  process. 

OPERATIVE  MEASURES. — To  mold  the  foot  into  a  corrected  posi- 
tion and  make  it  perfectly  flexible  it  will  be  necessary  to  divide  the 
tendons  and  fascia,  which  form  a  barrier  to  reduction.  The  opera- 
tions most  frequently  required  are  the  following: 

(1)  Subcutaneous  Tenotomy  of  Tendo  Achilles. — While  this  is 
a  simple  procedure,  two  precautions  should  be  observed:  (a)  strict 
aseptic  methods;  (b)  care  should  be  exercised  not  to  wound  the 
posterior  tibial  vessels  and  nerve  which  lie  on  the  inner  side  of  the 
tendon  and  are  separated  by  a  sufficient  interval  to  insure  their 
safety. 

The  subcutaneous  method  is  employed  to  avoid  a  cicatrix  at  the 
posterior  part  of  the  leg,  which  Kirmisson  has  seen  become  the  seat 
of  keloid  degeneration  and  contraction. 

The  knife  is  introduced  on  the  internal  side,  passing  flatwise  be- 
tween the  skin  and  tendon,  the  sharp  edge  of  the  blade  is  then  turned 
toward  the  tendon,  the  foot  flexed  to  put  the  tendon  on  tension,  and 
the  tendon  carefully  divided  from  without  in.  The  tendon  can  be 
felt  to  give  way  as  the  ends  separate.  The  wound  is  dressed  with 
aseptic  gauze, 


656 


DEFORMITIES  OF  THE  FOOT 


After  section  of  the  tendo  achilles  not  only  flexion  of  the  foot  is 
possible  and  the  equinus  position  relieved,  but  ofttimes  the  inversion 
also  disappears. 

(2)  Division  of  the  Plantar  Fascia. — When  the  plantar  fascia 
opposes  reduction  it  can  be  felt  as  a  broad  tense  ligament  beneath 
the  skin,  extending  from  the  os  calcis  to  the  base  of  the  great  toe. 
It  should  be  divided  at  its  most  prominent  point — midway  between 
the  heel  and  the  ball  of  the  foot.  The  fascia  is 
made  prominent  by  placing  the  great  toe  in  forced 
extension.  The  knife  is  inserted  on  the  inner  side 
of  the  sole  between  the  skin  and  the  fascia;  the 
sharp  edge  is  then  turned  inward  and  the  fascia 
divided  transversely  until  all  resisting  bands  yield. 
The  only  structure  to  be  avoided  is  the  internal 
plantar  artery,  which  is  deeply  placed  and  need 
cause  no  concern  if  the  operator  uses  ordinary 
care. 

(3)  Division  of  the  Tendons  of  the  Tibialis 
Anticus  and  Posticus. — To  correct  inversion  of  the 
foot  it  is  sometimes  necessary  to  divide  the  ten- 
dons of  the  tibial  muscles. 

The  tendon  of  the  tibialis  anticus  is  easily 
found,  since  it  presents  a  subcutaneous  prominence 
on  the  dorsum  of  the  foot  where  the  tendon  is 
made  tense  by  abducting  the  foot.  It  is  the  first 
tendon  in  front  of  the  ankle  external  to  the  inner 
malleolus  (Fig.  262).  The  artery  and  nerve  lie 
to  the  outer  side.  The  knife  is  introduced  to  the 
outer  side  of  the  tendon  beneath  the  skin  and 
the  tendon  divided  toward  the  bone. 

The  tendon  of  the  tibialis  posticus  is  the  tendon  immediately  be- 
hind the  internal  malleolus.  The  position  of  this  tendon  is  such 
that  safety  is  insured  only  by  open  division  (Fig.  263). 

An  incision  is  made  along  the  posterior  border  of  the  tibia  just 
above  the  malleolus,  the  tendon  next  the  bone  is  lifted  on  a  grooved 
director,  and  after  its  insertion  has  been  demonstrated  it  is  divided, 


FIG.  262. — RELA- 
TION OF  THE 
TENDONS  IN 
FRONT  OF  THE 
ANKLE.  (Davis.) 


CLUB    FOOT 


657 


(4)  If  the  deformity  does  not  yield  to  tenotomy  it  may  be  neces- 
sary to  resort  to  the  open  operation  of  Phelps,  which  consists  of 
complete  open  section  of  the  contracted  tissues  on  the  concave  side 
of  the  foot  by  an  incision  extending  from  the  tip  of  the  internal 
malleolus  obliquely  across  the  inner  border  to  the  base  of  the  first 
metatarsal.  This  inci- 
sion divides  tendons, 
muscles,  fascia,  liga- 
ments, and  all  resisting 
structures. 

Hemorrhage  should 
be  provided  for  by  use  of 
Esmarch's  bandage,  the 
incision  packed  with 
gauze,  and  sterile  dress- 
ings applied.  The  foot 
is  held  in  an  over-cor- 
rected position  while 
plaster  bandages  are  ap- 
plied. After  tenotomy 
the  wounds  are  protected 
by  sterile  dressings,  the 
foot  is  held  in  an  over- 
corrected  position  by  a 
light  plaster-of-paris  ban- 
dage extending  from  toes 
to  thigh. 

After-treatment. — At 
the  end  of  the  third  week 
the  patient  is  permitted 
to  walk,  at  the  end  of  the 
fourth  week  the  cast  is 
removed,  the  foot  thor- 
oughly stretched,  and  a  second  cast  applied  for  four  weeks.  When 
the  cast  is  finally  removed  some  form  of  walking  shoe  is  employed 
until  the  bony  structures  are  molded  into  permanent  relationships. 


FIG.  263. — RELATIONS  OF  THE  STRUCTURES  BEHIND 

THE  INTERNAL  MALLEOLUS. 
A.  Tendon  of  tibialis  posticus;  B.  tendon  of  flexor 

longus  digitorum ;  C.  posterior  tibial  artery ;  D. 

posterior    tibial    nerve;    E.    tendon    of    flexor 

longus  hallucis. 


658 


DEFORMITIES  OF   THE  FOOT 


The  Taylor  club-foot  shoe  is  one  of  the  most  efficient  of  these 
appliances  and  is  concealed  in  the  shoe  (Fig.  264).  Failures  and 
imperfect  results  are  caused  more  by  incomplete  after-treatment 
than  by  imperfect  operation.  After-treatment  in  these  cases  extends 
over  months  and  years;  it  involves  not  only  the  constant  wearing 
of  a  retentive  apparatus,  but  at  the  same  time  development  of  the 
musculature  by  massage  and  by  active  and  passive  gymnastics. 

TREATMENT  OF  CASES  THAT  HAVE  NEVER  BEEN  TREATED  AND 
BEGIN  TO  WALK,  OR  RELAPSING  AND  ADULT  CASES. — It  is  evident 

that  in  these  cases  the  bones  have 
become  permanently  deformed  and 
new  relationships  established,  hence 
nothing  short  of  a  bony  resection 
which  diminishes  the  mass  of  bone 
at  the  outer  border  of  the  foot  will 
be  an  efficacious  means  of  correc- 
tion. 

To  reduce  the  equinus  position 
— partial  or  total  removal  of  the 
astragulus. 

To  reduce  the  varus  position — 
removal  of  an  osseous  wedge  from 
the  external  base  of  the  tarsus 
(cuneiform  tarsectomy). 

Tarsectomy  is  a  valuable  pro- 
cedure in  those  inveterate  and  r?- 
lapsing  cases  which  have  failed  t  > 
be  benefited  by  lesser  operations,  but  Kirmisson's  rule  should  be  re- 
membered, that  "all  these  operations  are  to  be  considered  as  excep- 
tional and  should  have  no  place  in  the  treatment  of  club  foot  in  the 
first  period  pf  infancy  and  childhood." 

Tarsectomy  may  contemplate  an  osteotomy  of  the  neck  of  the 
astragulus,  removal  of  the  head  and  neck,  or,  in  extreme  cases, 
enucleation  of  the  astragulus ;  or  a  wedge  of  bone  may  be  .removed 
from  the  outer  side  of  the  foot  at  the  junction  of  the  os  calcis  and 
cuboid.  These  operations  should  be  done  under  strict  aseptic  con- 


FIG.  264. — TAYLOR'S  CLUB-FOOT  RE- 
TENTION SHOE  APPLIED.  (Bradford 
and  Lovett.) 


CLUB    FOOT  659 

ditions  and  by  surgeons  of  experience.     The  after-treatment  is  the 
same  as  in  tenotomies. 


ACQUIRED    CLUB    FOOT 

Acquired  club  foot  may  be  the  result  of  infantile  paralysis, 
cerebral  spastic  paralysis,  cicatrices,  fractures,  or  joint  disease. 

Club  foot  following  traumatism  is  due  to  fractures,  sprains,  or 
burns.  The  deformity  following  fractures  and  sprains  is  treated 
by  forcible  reduction  and  tenotomy  and  osteotomy  as  indicated.  In 
case  of  burns  the  scar  tissue  should  be  removed  and  skin  grafting 
done. 

In  deformities  following  tuberculous  disease  of  the  ankle  cor- 
rective measures  may  be  applied  only  after  the  tuberculous  process 
has  remained  cured  for  a  year. 


PARALYTIC    CLUB    FOOT 

Among  the  diseases  of  the  nervous  system  in  children  anterior 
poliomyelitis  is  observed  most  frequently.  As  a  result  of  this  disease 
the  lower  extremities  are  frequently  paralyzed  either  partially  or 
totally.  As  a  rule,  however,  the  results  of  infantile  paralysis  are 
finally  localized  in  certain  groups  of  muscles,  or  sometimes  a  single 
muscle,  especially  those  of  the  leg;  hence  deformities  of  the  feet  are 
a  frequent  sequelss  and  call  for  surgical  intervention. 

The  paralyzed  muscles  atrophy  and  undergo  fibrous  changes; 
there  is  consequently  a  loss  of  equilibrium  among  the  muscle  groups, 
and,  the  action  of  the  antagonists  being  unopposed,  there  result 
vicious  attitudes. 

It  is  obvious  that  if  all  the  muscles  of  the  leg  are  paralyzed  the 
result  will  be  a  flail-like  foot,  which  can  be  made  to  assume  any  posi- 
tion, but  in  paralytic  club  foot  the  lesion  is  usually  partial  and  it 
is  the  loss  of  function  in  certain  groups  of  muscles  which  causes  the 
deformity.  To  cite  a  common  example — if  the  flexors  of  the  foot 


660  DEFORMITIES  OF  THE  FOOT 

are  paralyzed  the  powerful  extensors  will  gradually  pull  the  foot 
into  a  position  of  equinus  or  equinovarus,  or,  if  the  conditions  are 
reversed,  the  foot  will  assume  a  position  of  calcaneus  or  calcaneo- 
valgus. 

These  deformities  usually  appear  from  two  to  six  months  after 
the  primary  infection. 

Club  foot  of  paralytic  origin  is  to  be  differentiated  from  congen- 
ital club  foot  in  that  it  is  very  much  less  severe  and  the  foot  is  less 
fixed  in  its  vicious  position  by  the  retraction  of  muscles  and  liga- 
ments (Kirmisson). 

Treatment. — The  treatment  of  the  primary  lesion  belongs  to 
medicine.  Surgery  is  concerned  only  with  the  treatment  of  the 
deformity. 

The  indications  for  treatment  in  these  cases  are: 

(a)  The  application  of  electricity  and  massage  to  prevent  de- 
generation of  the  affected  muscles.     The  galvanic  current  should  be 
applied  as  soon  as  possible — as  soon  as  the  diagnosis  is  made  and 
the  febrile  period  has  terminated.     If  the  case  is  seen  early,  before 
the  deformity  is  fixed,  electricity  and  massage  alone  are  indicated. 
If  the  case  is  seen  later,  when  the  deformity  is  fixed,  it  is  proper  to 
correct  the  deformity  before  applying  electric  treatment. 

(b)  Correction  of  the  Deformity. — If  the  case  is  seen  early  it 
will  be  easy  to  prevent  fixation  of  the  foot  in  a  vicious  position  by 
means  of  massage  and  passive  movements.     Even  slight  contractures 
of  the  muscles  may  be  overcome ;  but  when  the  muscular  contractions 
are  more  pronounced,  with  a  tendency  to  fixation  of  the  foot  in  a 
vicious  position,  further  deformity  may  be  prevented  by  the  use  of 
some  apparatus  like  the  Taylor  varus  shoe  (see  p.  658).     In  severe 
cases,  however,  and  in  adults  it  will  be  necessary  to  resort  to  tenot- 
omies  (see  p.  656).     In  suitable  cases  active  muscular  traction  may 
be  accomplished  by  activating  the  paralyzed  muscles  by  means  of 
nerve-plastics,  or  by  transplantation  of  tendons. 

Tendon  anastomosis  is  a  complex  and  delicate  operation.  Ana- 
tomical knowledge  and  surgical  skill  should  be  possessed  by  those 
who  attempt  this  procedure. 

The  aim  of  tendon  transplantation  is  to  substitute  the  action  of 


TALIPES    EQUINUS 


661 


a  sound  muscle  for  that  of  a  muscle  which  is  paralyzed.  A  thor- 
ough study  of  the  active  movements  by  electric  examination  and  an 
estimate  of  the  value  of  the  various  muscles  are  necessary  prelimi- 
naries to  a  rational  and  efficient  operation. 


TALIPES  EQUINUS 

Pathology. — Talipes  equinus  or  pes  equinus  is  that  condition  of 
the  foot  in  which  it  is  held  in  a  position  of  plantar  flexion,  the  heel 
is  raised  from  the  ground  and  the  patient  walks  on  the  ball  of  the 
foot  (Fig.  265).  The  foot  may  be  extended  to  a  straight  line  with 
the  leg,  so  that  the  weight  is  borne  on  the  heads  of  the  metatarsals 
and  the  toes  are  in  dorsiflexion. 

The  deformity  is  either  congenital  or  acquired.     As  a  congenital 


FIG.  265. — VARIETIES  OF  DEFORMITIES  OF  THE  FOOT. 
A.  Talipes  calcaneus;  B.  Talipes  varus;  C.  Talipes  valgus;  D.    Talipes   equinus. 


deformity  it  is  extremely  rare,  and  is  treated  by  manipulation  and 
retention  in  an  over-corrected  position  by  plaster  cast.  To  accom- 
plish this  it  may  be  necessary  to  tenotomize  the  tendo  achilles. 

Acquired  pes  equinus  may  be  the  result  of  anterior  poliomyelitis 
with  partial  paralysis  affecting  the  anterior  tibial  muscles  and  con- 
traction of  the  gastrocnemius  and  soleus ;  or  it  may  be  due  to  spastic 
paralysis,  neuritis,  shortening  of  the  leg  by  fracture  or  hip  disease, 
malposition  from  long  confinement  to  bed,  and  posterior  cicatrices. 

Symptoms. — Pain,  limp,  and  deformity.  Corns  and  callosities 
develop  where  the  weight  is  borne  and  the  toes  are  dorsiflexed. 


662  DEFORMITIES  OF  THE  FOOT 

Fixation  of  the  deformed  position  and  inability  to  dorsally  flex  the 
foot  are  diagnostic. 

Treatment. — Slight  cases  may  be  treated  by  manipulation,  but 
the  majority  of  cases  will  require  division  of  the  tendo  achilles  and 
forcible  reduction  under  ether  with  retention  in  plaster  bandages  for 
three  or  four  weeks.  Some  cases  may  be  so  severe  as  to  require  re- 
moval of  a  wedge  of  bone  from  the  front  of  the  joint. 


PES  CAVUS 

Pathology. — Pes  cavus  (hollow  foot)  is  that  condition  of  the  foot 
in  which  the  hollow  or  arch  of  the  foot  is  exaggerated  (Fig.  266). 
The  typical  deformity  is  shown  in  the  foot  of  the  high-bred  Chinese 
woman.  It  is  a  rare  congenital  deformity.  The  acquired  form  may 
be  the  result  of  infantile  paralysis  (paralysis  of  the  interossei  and 
lumbricales  and  the  muscles  inserted  into  the  sesamoid  bones  of  the 
great  toe),  Duchenne ;  or  the  wearing  of  shoes  that  are  too  short. 

The  sole  is  abnormally  arched,  the  dorsum  is  abnormally  promi- 
nent, and  the  plantar  fascia  forms  a  thick  band  from  the  heel  to 

ball  of  great  toe. 

The  toes  also  have  a  characteristic  de- 
formity— "claw  toe" — caused  by  extension 
at  the  metatarso-phalangeal  joints,  and 
flexion  at  the  first  interphalangeal  joints. 
It  is  obvious  that  this  deformity  after  a 
time  becomes  very  painful,  since  the 
weight  is  thrown  on  the  forward  part  of 
the  foot,  callosities  form  on  the  sole  over 
FIG.  266.— PES  CAVUS.  the  heads  of  the  metatarsals  and  on  the 

dorsal  surface  of  the  contracted  toes. 

Treatment. — The  treatment  consists  in  restoration  of  the  muscu- 
lar balance,  reduction  of  the  deformity,  and  immobilization  in  good 
position.  To  reduce  the  deformity  it  may  be  necessary  to  divide 
the  plantar  fascia  (see  p.  657)  or  contracted  tendons. 


FLAT-FOOT  663 

After  reduction  the  foot  is  held  in  the  corrected  position  by  a 
plaster  bandage. 

Lovett  recommends  that  when  the  patient  begins  to  walk  he 
should  have  a  stiff  flat  steel  plate  run  the  length  of  the  shoe  be- 
tween the  leather  soles,  running  from  which  over  the  dorsum  of  the 
foot  is  a  stout  leather  strap.  The  object  of  this  is  that  at  each  step 
downward  pressure  is  exerted  on  the  dorsum  of  the  foot. 


TALIPES   CALCANEUS 

Talipes  calcaneus  is  that  condition  of  the  foot  in  which  it  is 
held  in  dorsal  flexion.  The  patient  walks  on  the  heel  (see  Fig.  265). 
It  is  rarely  congenital;  usually  the  result  of  infantile  paralysis.  The 
congenital  form  is  usually  amenable  to  manipulative  correction  and 
retention  in  plaster  bandages. 

In  the  acquired  form  there  is  usually  paralysis  of  the  muscles 
of  the  calf,  the  relaxed  tendo  achilles  permits  the  os  calcis  to  drop 
until  it  is  in  a  straight  line  with  the  leg. 

This  deformity  is  also  seen  in  caries  of  the  ankle  joint  and  after 
rupture  of  the  calf  muscles. 

Treatment. — The  treatment  consists  in  manipulative  correction 
and  fixation;  in  extreme  cases  tenotomy  of  the  dorsal  flexors,  short- 
ening of  the  tendo  achilles.  In  paralysis  of  the  gastrocnemius 
tendon  transplantation  may  be  considered. 

After  reduction  is  obtained  a  retention  shoe  may  be  applied. 


FLAT-FOOT 

Talipes  valgus  is  a  deformity  in  which  the  foot  is  pronated  and 
abducted,  the  plantar  arch  obliterated,  so  that  the  inner  border  of 
the  foot  comes  in  contact  with  the  ground  (Fig.  267).  Willard  esti- 
mates that  one-fifth  of  the  deformities  of  the  body  presenting  them- 
selves to  the  surgeon  are  from  weakened  tarsal  arches. 

Anatomical  Considerations. — A    normal    foot    is    the    product    of 


DEFORMITIES  OF   THE  FOOT 


normal  development,  and  normal  development  is  often  checked  by 
ambitious  parents  who  encase  the  foot  in  a  shoe  that  retards  growth 
and  then  encourage  precocious  walking  by  all  sorts  of  inducements, 
even  to  the  use  of  apparatus  such  as  walking  chairs.  Bare-footed 
children  who  are  permitted  to  exercise  their  walking  instinct  when 
and  how  nature  intended  are  rarely  the  victims  of  flat  foot. 

Parents  should  be  instructed  by  the  physician  in  the  physiology 
of  locomotion  and  in  this  should  be  accentuated  two  important 
points : 

First :  The  feet  of  small  children  should  not  be  encased  in  shoes. 
There  should  be  nothing  to  compress  the  foot — nothing  to  impede 

the  free  movements  of 
the  toes  since  the  muscles 
of  the  toes  are  the  sup- 
porting tendons  of  the 
foot.  Children  should 
be  encouraged  to  walk 
barefooted  when  possible, 
and  when  foot  covering 
is  required  the  use  of  the 
sandal  is  recommended, 
since  it  allows  unhin- 
dered movements  of  the 
toes. 

Second:  Walking 
should  always  be  preceded  by  crawling — to  attempt  to  eliminate 
the  "crawling  period"  is  to  prepare  the  way  for  deformities.  The 
process  by  which  the  child  establishes  locomotion  in  the  upright 
position  is  only  a  repetition  of  its  biological  development.  In 
the  developmental  history  of  the  race  crawling  preceded  walking, 
and  if  the  child  is  left  to  his  own  instincts  he  will  naturally  be- 
gin moving  about  by  crawling,  thus  developing  the  bones,  mus- 
cles, and  ligaments  for  the  later  weight;  and  when  the  prepara- 
tion of  these  structures  is  sufficient,  the  crawling  period  is  spon- 
taneously carried  over  into  the  walking  period.  Only  when  the 
child  stands  up  alone  and  of  his  own  volition  tries  to  balance  him- 


FLAT-FOOT. 


PLAT-FOOT  GG5 

self  by  objects  and  thus  move  about  should  he  be  allowed  to  walk 
(Spitzy). 

Varieties. — Flat  foot  is  either  congenital  or  acquired.  Con- 
genital flat  foot  is  rare — occurs  only  in  a  small  percentage  of  new- 
borns  as  a  result  of  embryological  position.  Here  it  must  be  ob- 
served that  the  generous  layer  of  fat  makes  the  foot  of  the  new-born 
appear  flat,  but  is  not  the  apparent  absence  of  the  arch  of  the  new- 
born that  constitutes  the  deformity,  but  the  rolling  out  of  the  sole 
and  the  outward  displacement  of  the  foot  in  relation  to  the  leg  so 
that  the  internal  malleolus  is  abnormally  prominent. 

The  treatment  of  this  congenital  deformity  is  by  manipulative 
correction  and  retention  in  plaster  bandages.  Do  not  allow  the 
child  to  begin  walking  without  proper  support  to  the  plantar  arch. 

Acquired  Flat  Foot. — It  is  evident  that  this  deformity  may  be 
the  result  of  rachitis,  and  it  is  often  associated  with  other  rachitic 
deformities  (note  the  frequency  of  knock-knee  with  flat  foot).  It 
may  also  occur  as  the  result  of  infantile  paralysis,  diseases  of  the 
ankle  joint,  and  Pott's  fracture. 

Typical  flat  foot  is  the  static  variety  and,  as  Lovett  has  tersely 
put  it,  "it  is  an  expression  of  a  disproportion  between  the  body 
weight  and  the  sustaining  power  of  the  muscles  and  ligaments." 

Precocious  walking  means  that  weight  is  superimposed  on  struc- 
tures not  yet  prepared  for  the  weight-bearing  function — the  use  of 
unsuitable  shoes,  occupations  requiring  prolonged  standing  on  hard 
floors,  excess  of  body  weight,  all  infer  a  disproportion  between  the 
burden  and  the  burden  bearer — the  result  is  over-stretched  liga- 
ments, relaxed  ligaments,  falling  of  the  arch  till  the  entire  plantar 
surface  comes  in  contact  with  the  ground,  bringing  pressure  upon 
points  that  are  not  adapted  to  withstand  it,  throwing  the  joint  sur- 
faces out  of  line,  and  giving  rise  to  a  condition  which  produces  pain 
and  fatigue  when  the  patient  walks. 

Symptoms. — A  child  is  brought  to  the  surgeon  because  the  parents 
have  noticed  that  the  walk  is  heavy,  the  foot  is  pointed  outward, 
the  shoes  are  worn  out  on  the  inner  side:  The  child  tires  out  easily 
and  always  wants  to  be  carried. 

EXAMINATION. — The  patient  should  be  stripped  so  that  the  feet, 


666  DEFORMITIES  OP  THE  FOOT 

leg,  hips,  and  back  can  be  observed.  The  child  is  stood  upon  a  flat 
table  and  the  observation  recorded.  It  will  be  noted  that  the  foot 
appears  elongated  and  broader.  It  is  pointed  out,  and  the  internal 
malleolus  is  more  prominent. 

The  plantar  arch  is  much  diminished  or  flat  on  the  ground,  while 
the  instep  is  flat  and  often  concave.  Observe  the  foot  from  behind, 
where  the  valgus  deformity  is  well  marked. 

Note  that  the  axis  of  the  leg,  instead  of  falling  through  the 
middle  of  the  heel,  falls  to  the  inner  side.  There  are  certain  pain- 


FIG.  268. — PKINT  OF  SOLES  OF  A  FLAT-FOOT  AND  A  NORMAL  FOOT. 

ful  points  in  flat  foot,  viz. :  At  the  inner  border  of  the  foot  in  front 
of  the  internal  malleolus  and  at  the  base  of  the  first  and  fifth 
metatarsal  bones. 

Make  an  imprint  of  the  tread  for  purposes  of  record  by  wetting 
the  sole  with  water  and  have  the  patient  stand  for  an  instant  upon 
a  piece  of  brown  wrapping  paper  smoothly  spread  on  a  hard  table 
or  floor.  Lift  the  foot  and  trace  the  outline  of  the  wet  imprint  with 
pencil.  Note  the  difference  in  the  normal  and  flat  foot  (Fig.  268). 

Flat  foot  is  often  associated  with  hallux  valgus  and  hammertoe. 

Diagnosis. — The  diagnosis  in  pronounced  cases  is  not  difficult; 


FLAT-FOOT  667 

the  lighter  cases,  however,  where  changes  in  the  arch  are  slight,  are 
often  puzzling.  Every  painful  foot  should  receive  a  thorough  ex- 
amination and  all  "growing"  pains  in  knee,  hip,  and  back  should 
suggest  inspection  of  the  foot.  The  lazy  diagnosis  of  rheumatism 
in  painful  foot  often  means  overlooked  flat  foot.  One  precaution 
needs  to  be  mentioned — remember  that  a  painful  pronated  foot 
sometimes  signifies  tuberculous  disease  of  the  tarsus.  A  careful  con- 
sideration of  the  position,  the  anatomical  changes,  and  the  character- 
istic painful  points  and  X-ray  will  clear  up  the  diagnosis. 

Prognosis. — If  the  deformity  remains  untreated  the  deforming 
factors  cooperate  to  make  the  deformity  permanent.  Early  cases 
are  cured  by  proper  treatment.  Severe  cases  are  greatly  benefited. 

Treatment  should  be,  first,  prophylactic,  and,  second,  curative 
measures. 

The  PROPHYLAXIS  of  flat  foot  should  consist  principally  in  the 
proper  development  of  the  foot  of  the  child  by  observing  the  physi- 
ology of  locomotion,  which  emphasizes  two  important  points : 

First:  Avoid  the  compression  effects  of  shoes  as  much  as  pos- 
sible and  permit  the  foot  to  grow  in  a  normal  way. 

Second :  Discourage  the  pernicious  practice  of  precocious  walk- 
ing, and  make  it  plain  to  parents  that  in  the  development  of  loco- 
motion crawling  is  an  essential  preliminary  to  walking  (see  p.  664). 

CURATIVE  MEASURES  in  children  contemplate  the  restoration  of 
the  foot  to  the  normal  position,  in  which  it  is  held  by  proper  support 
until  by  securing  normal  anatomical  relations  and  normal  muscular 
equilibrium  the  temporary  artificial  support  can  be  abandoned. 

The  simple  wearing  of  a  support  may  prevent  further  sinking 
and  diminish  pain,  but  it  will  not  remold  the  foot  to  the  normal 
type.  Hence,  proper  support  to  the  arch  must  be  supplemented  by 
general  treatment — sunshine,  sea  air,  massage,  gymnastics  for  secur- 
ing muscular  control. 

Supports. — Wherever  there  is  a  tendency  to  pronated  foot  the 
tread  may  be  altered  by  raising  the  inner  side  of  the  sole  of  the 
shoe  from  one-sixteenth  to  one-quarter  inch  and  thus  throwing  the 
weight  away  from  the  plantar  arch  to  the  outer  side  of  the  foot. 

It  is  highly  important  that  the  shoe  should  be  of  proper  width, 


668  DEFORMITIES  OF  THE  FOOT 

so  that  the  toes  are  not  squeezed  together.  It  should  be  as  wide  as 
the  weight-bearing  foot  in  front  (Lovett).  It  is  also  important  to 
instruct  the  patient  not  to  toe  out  in  walking  but  to  walk  with  feet 
straight  in  front.  There  are  a  great  variety  of  sole  plates  of  dif- 
ferent materials,  their  aim  being  to  form  a  splint  for  the  inner  plan- 
tar aspect  of  the  foot. 

A  reliable  support  is  made  of  tempered  spring  steel  shaped  to 
fit  the  arch  of  a  normal  sole,  and  worn  inside  the  shoe.  The  most 
accurate  method  is  to  have  the  steel  support  forged  to  fit  the  indi- 
vidual plaster  model. 

Gymnastics  for  the  Deficient  Muscles. — The  use  of  supports  is 
to  be  regarded  as  temporary  while  the  muscles  and  ligaments  are 
being  developed,  so  that  at  the  proper  time  the  supports  can  be 
gradually  withdrawn. 

For  small  children  Willard  recommends  that  a  large  rubber  ball, 
eight  or  ten  inches  in  diameter,  be  attached  to  the  shoe  by  an  elastic 
cord,  and  that  forcible  and  repeated  striking  of  this  ball  with  the 
big  toe  by  the  action  of  the  adductors  of  the  foot  will  develop  the 
deficient  muscles  and  keep  up  the  interest  by  affording  amusement 
as  a  return  ball.  For  older  children  they  should  be  instructed  to 
walk  on  tip  toes  as  a  daily  systematic  exercise,  or  to  raise  them- 
selves gradually  on  their  toes  and  while  in  this  position  separate 
the  heels  as  widely  as  possible,  then  slowly  lowered  to  the  ground 
(Bradford  and  Lovett). 

When  the  flat  foot  is  of  a  severe  form  where  there  is  permanent 
contracture  it  is  obvious  that  the  methods  heretofore  described  will 
be  of  little  use.  It  will  be  necessary  to  forcibly  correct  the  de- 
formity under  ether  and  retain  the  foot  by  'plaster  bandages  in  a 
position  of  extreme  adduction  and  inversion  for  three  weeks.  After 
the  cast  is  taken  off  the  previous  methods  of  treatment  will  be 
applicable. 

Operative  Treatment. — Various  operations  have  been  proposed 
for  the  relief  of  those  severe  cases  which  are  intractable  to  forcible 
corrective  measures.  The  most  efficient  procedure  contemplates  the 
removal  of  a  wedge-shaped  piece  of  bone  from  the  tarsus  with  the 
base  downward  at  the  point  of  greatest  inward  convexity.  The  foot 


TUBEECULOSIS    OF    THE    ANKLE  66<J 

is  then  brought  to  an  over-corrected  position  and  retained  in  plaster 
bandages  for  six  or  eight  weeks. 


CHAPTER  LXXX 

AFFECTIONS    OF    THE    ANKLE    AND    TOES 

TUBERCULOSIS  OF  THE  ANKLE 

Pathology. — Tuberculosis  of  the  ankle  joint  and  bones  of  the 
tarsus  is  quite  frequent,  while  in  the  metatarsals  and  phalanges  it 
is  relatively  rare.  Of  the  three  bones  entering  into  the  joint  we 
find  the  astragulus  is  the  usual  site  of  infection.  Its  spongy  char- 
acter offers  a  fertile  field  for  tuberculous  proliferation  and  unless 
checked  by  treatment  it  spreads  through  the  tarsal  synovia  and 
invades  the  neighboring  tibia,  fibula,  calcaneum,  scaphoid,  cuboid, 
and  cuneiform  bones.  Left  untreated  the  process  pursues  its  usual 
course  and  after  a  time  the  entire  tarsal  region  is  tunneled  with 
fistulse. 

Symptoms. — The  onset  of  the  disease  is  slow  and  is  apt  to  be  asso- 
ciated with  a  sprain.  Sprains  which  do  not  yield  promptly  to  treat- 
ment, but  show  a  tendency  to  chronicity,  should  be  looked  upon  with 
suspicion. 

The  usual  symptoms  of  joint  tuberculosis — limp,  muscular 
spasm,  pain,  swelling,  and  muscular  atrophy — follow  in  succession. 
It  is  well  to  remember  that  the  natural  barriers  of  the  joint  are 
the  lateral  ligaments,  hence  the  distention  of  the  joint  is  evident  at 
first  only  in  front  and  behind  and  most  pronounced  behind.  Hence 
look  for  puffiness  behind  in  the  retromalleolar  depressions — note  if 
the  prominence  of  the  achilles  tendon  is  diminished. 

Pain  may  be  spontaneous,  or  it  may  be  provoked  by  pressure  on 
the  astragulus,  or  at  the  interarticular  line.  As  in  all  arthritic  con- 
ditions, the  ankle  assumes  a  vicious  attitude — an  attitude  of  equinus 
(the  patient  walks  on  his  toes),  which  must  be  duly  appreciated  in 
order  to  combat  by  subsequent  treatment. 


670  AFFECTIONS  OF  THE  ANKLE  AND  TOES 

The  latter  symptoms  are  those  of  advanced  tuberculous  joints — 
abscess,  fistulization,  and  secondary  infection.  The  diagnosis  is 
usually  not  difficult ;  sprain,  painful  flat  foot,  and  infectious  arthritis 
are  eliminated  by  the  history  and  the  aid  of  the  X-ray.  An  X-ray 
picture  will  be  of  the  greatest  service  when  a  plate  of  both  feet  can 
be  compared.  The  von  Pirquet  tuberculin  skin  reaction  is  useful 
in  small  children. 

Prognosis. — Conservative  treatment  in  children  usually  gives  ex- 
cellent results,  both  in  the  cure  of  the  disease  and  function  of  the 
joint.  The  period  of  time  over  which  the  treatment  extends  is 
much  shorter  than  in  disease  of  the  larger  joints. 

Treatment. — GENERAL  TREATMENT  is  of  prime  importance  and 
every  effort  must  be  made  by  proper  nutrition,  unlimited  sunshine, 
and  fresh  air  to  so  improve  the  tissues  that  the  tubercle  bacilli  will 
cease  to  thrive. 

LOCALLY,  physiological  rest  in  good  position,  correction  of 
vicious  attitude,  and  immobilization  of  the  articulation.  The  blood 
supply  to  the  diseased  area  should  be  increased  by  producing  an 
artificial  chronic  congestion  after  the  method  of  Bier  (see  Joint 
Tuberculosis,  p.  207). 

The  use  of  tuberculin  has  been  followed  by  excellent  results  and 
shortens  the  convalescent  period  (see  p.  188). 

As  soon  as  the  diagnosis  is  made  the  joint  should  be  immobilized 
in  a  plaster  cast  extending  from  the  toes  to  the  bend  of  the  knee, 
the  foot  forming  a  right  angle  with  the  leg. 

Protection  from  weight-bearing  is  provided  by  putting  a  high- 
soled  shoe  on  the  sound  foot  and  the  use  of  crutches.  The  cast 
should  be  renewed  every  two  months,  and  after  all  inflammatory 
symptoms  (pain,  swelling,  etc.)  have  disappeared  for  three  months 
it  may  be  discontinued,  the  ankle  bandaged,  and  the  patient  per- 
mitted to  walk  with  crutches.  After  another  period  of  two  or  three 
months  more  freedom  may  be  allowed.  The  return  to  normal  func- 
tion must  be  slow  and  very  gradual,  for,  as  Spitzy  observes,  "in 
tubercular  lesions,  which  on  clinical  examination  appear  cured, 
there  are  often  foci  not  yet  completely  extinguished." 

Abscess  formation  is  treated  by  aspiration,  removal  of  contents 


DEFORMITIES    OF    THE    TOES 


671 


by  suction,  and  the  injection  of  a  five  per  cent,  emulsion  of  iodoform 
and  glycerin. 

Operations  in  children  except  to  correct  deformities  by  ap- 
propriate tenotomies  and  osteotomies  after  all  inflammatory  phenom- 
ena have  disappeared  are  not  to  be  considered  unless  persistent  con- 
servative treatment  fails  to  stop  the  progress  of  the  disease  or  the 
indications  are  vital. 


DEFORMITIES  OF  THE  TOES 


While  a  few  of  the  deformities  of  the  toes  are  congenital  (Fig. 
269)  and  even  hereditary,  it  must  be  conceded  that  foot  and  toe  de- 
formities are  largely 
due  to  ill-fitting  foot- 
gear— the  shoes  are 
too  short,  too  tight, 
or  too  pointed. 
While  these  deformi- 
ties usually  appear  in 
their  full  develop- 
ment only  in  adult 
life,  yet  it  is  time 
that  parents  appreci- 
ate the  prevention  of  FIG.  269. — SUPERNUMERARY  TOE. 
these  deformities  and  their  attending  disabilities  by  an  intelligent 
supervision  of  the  growing  child's  foot  and  the  selection  of  properly 
constructed  shoes. 


CLAW    FOOT 


We  occasionally  find  in  children  a  vertical  position  of  the  toes — 
the  free  extremity  of  the  toe  is  turned  toward  the  plantar  surface, 
producing  a  claw-like  appearance  of  the  terminal  portion  of  the  toes. 
This  arching  of  the  toes  causes  a  corresponding  sinking  downward 


672 


AFFECTIONS  OF  THE  ANKLE  AND  TOES 


of  the  heads  of  the  metatarsals.      This  deformity  is  the  result  of 
too  short  shoes  and  atrophy  of  the  interossei  muscles. 

Treatment.  — The  deformity  is  corrected  by  lengthening  the  short- 
ened flexor  tendons  and  raising  the  sunken  metatarsals  by  a  well- 
fitting  cast. 


HALLUX   VALGUS 

Hallux  valgus  is  a  deformity  of  the  great  toe  characterized  by 
a  deviation  outward,  sometimes  lying  under  or  across  its  fellows, 
and  in  severe  cases  forming  a  right  angle  with  the  first  metatarsal 

(Fig.  270).  It  is  usually  an 
affection  of  adult  life,  yet  it  oc- 
casionally is  seen  in  children. 

Etiology. — The  cause  of  this 
deformity  in  many  cases  is  the 
pressure  of  ill-fitting  shoes. 
Still  Kirmisson  believes  that  in 
the  great  majority  of  cases  de- 
formities of  the  toes  are  the  re- 
sult of  various  pathological 
causes,  which  in  children  are  of 
paralytic,  congenital,  or  even  hereditary  origin ;  and  when  appearing 
in  adolescence  they  are  the  result  of  some  defect  in  development, 
being  comparable  to  those  defects  in  ossification  which  cause  genu 
valgum  and  genu  varum. 

Pathology. — Young  has  found  that  there  is  often  present,  in  the 
first  tarsometatarsal  joint  in  subjects  afflicted  with  this  deformity, 
a  wedge-shaped  supernumerary  bone  similar  or  related  to  the  inter- 
metatarseum  described  by  Dwight.  It  is  obvious  that  this  primary 
deformity  gives  rise  to  secondary  changes  in  neighboring  structures. 
The  pressure  on  the  soft  parts  on  the  outer  side  of  the  toe  causes 
the  nail  to  penetrate  the  tissues  and  produce  the  painful  affection 
of  ingrowing  toe  nail. 

The  continued  pressure  on  the  second  toe  causes  it  to  assume  a 


FIG.  270. — HALLUX  VALGUS. 


DEFOEMITIES    OF    THE    TOES  673 

cramped  position,  which  in  time  results  in  hammer-toe.  Again, 
pressure  effects  lead  to  the  development  of  an  exostosis  at  the  inter- 
nal portion  of  the  head  of  the  first  metatarsal  bone  and  the  produc- 
tion of  a  bursa  (bunion),  which  may  become  inflamed  and  suppurate. 
These  severe  forms  are  to  be  seen  in  adults  rather  than  in 
children. 

When  once  the  great  toe  deviates  outward  then  the  extensor 
proprius  hallucis  tendon  exaggerates  the  condition  and  is  an  impor- 
tant factor  in  its  progress. 

Symptoms. — The  symptoms  are  in  proportion  to  the  degree  of  the 
deformity.  Pain  in  the  affected  joint  and  in  the  neighboring  toes. 
Difficulty  in  walking,  loss  of  elasticity  in  the  gait,  and  the  possible 
complications  already  described. 

Diagnosis. — The  diagnosis  is  clear  from  the  evident  deformity. 
Untreated,  the  lesion  grows  progressively  worse. 

Treatment. — First  and  most  important  are  proper  shoes,  as  wide 
as  the  weight-bearing  foot  in  front,  with  a  straight  inner  front  edge. 
Separately  toed  stockings  will  also  aid.  In  mild  cases  a  splint  of 
pasteboard,  to  which  the  toe  is  bound,  so  as  to  pull  it  inward;  or 
a  light  sole  plate  with  a  toe-post  elevated  between  the  first  and 
second  toes  is  useful.  In  severe  cases  it  is  necessary  to  resort  to 
resection  of  the  head  of  the  metatarsal  with  the  condyle  of  the 
phalanx — in  some  cases  division  of  the  extensor  proprius  hallucis 
may  also  be  required. 

The  straightened  toe  is  retained  in  plaster  bandages  for  four 
weeks. 


HALLUX   VAEUS 

Hallux  varus  is  a  deformity  in  which  the  great  toe  is  deviated 
inward.  It  is  a  rare  deformity  of  infancy  and  young  children  and 
is  often  associated  with  club  foot,  knock-knee,  and  with  the  devia- 
tion of  the  foot  into  a  valgus  position,  which  accompanies  congenital 
absence  of  the  fibula  (Hoffa).  These  cases  are  usually  amenable  to 
the  simple  wearing  of  a  shoe. 


674 


AFFECTIONS  OF  THE  ANKLE  AND  TOES 


HAMMER-TOE 

This  deformity  consists  of  a  hyperextension  of  the  proximal 
phalanx  and  flexion  of  the  second  phalanx,  so  that  the  toe  touches 
the  ground  at  its  free  extremity  (Fig.  271).  The  second  toe,  being 
the  longest,  is  usually  affected,  sometimes  the  third,  rarely  the  other 
toes.  The  congenital  and  hereditary  origin  cannot  be  denied,  yet  it 

is  usually  caused  by  too  short 
shoes  and  is  also  associated  with 
liallux  valgus  and  flat  foot. 

It  is  obvious  that  the  defor- 
mity gives  a  prominence  to  the 
toe  which  invites  pressure  cal- 
losities, and  on  the  dorsum  is 
frequently  formed  a  bursa 
which  inflames  and  suppurates. 

Treatment. — First  and  most  important,  proper  shoes,  sufficiently 
broad  and  long.  In  children  the  deformity  may  be  corrected  by 
strapping  the  toe  to  a  plantar  splint.  There  are,  however,  many 
recurrences  and  the  intractable  cases  should  be  subjected  to  opera- 
tion— division  of  the  flexor  tendons  and  contracted  fascia  beneath 
the  toe;  or  resection  of  the  interphalangeal  joint;  or  partial  ampu- 
tation of  the  toe.  The  entire  toe  should  not  be  removed,  since  the 
neighboring  toes  tend  to  deviate  toward  the  vacant  space  and  severe 
hallux  valgus  may  result. 


FIG.  271. — HAMMER-TOE. 


INDEX 


INDEX 


Abdomen   and   pelvis,   conditions  in- 
volving : 

appendicitis,  499 
congenital  affections,  466 
exstrophy  of  the  bladder,   489 
hernia,  470 

malformations  of  the  urachus,  469 
Merckel's  diverticulum,  466 
peritonitis,  pneumococcus,  497 

tuberculous,  494 
stenosis  of  the  pylorus,  congenital 

hypertrophic,    492 
Abortion,  effects  of,  on  infant,  16 
Abscess,    cerebral,    see    Cerebral   ab- 
scess 

pointing  on  neck,  170,  171,  172 
Activity  of  children,  18 
Adenitis,  simple  acute,  arsenic  in,  165 
cod  liver  oil  in,  165 
diagnosis  of,  162 
etiology  of,  159 
lesions  of,  160 
mumps  and,  162 
salivary  calculi  simulating,  161 
suppuration  in,  164 
symptomatology  of,  160 
treatment  of,  162 
simple  chronic,  diagnosis  of,  166 
symptoms  of,  166 
treatment  of,  166 
syphilitic,  167 

tuberculous,  see  Tuberculous  aden- 
itis 

Adenoid  vegetations,  384 
Age  as  a  factor  in  diagnosis,  11 

677 


Agnew's    operation    for    syndactyly, 

602 

Air  passages,  foreign  bodies  in,  387 
intubation  of,  389 
tracheotomy  and,  392 
Alcohol  as  a  tonic,  100 
Analgesia,  266 
Anemia,  77 
Anesthesia,    see   also    Post-anesthetic 

care 

general  considerations  of,  57 
hemoglobin  percentage  and,  77 
infiltration,  71,  72 
local,  by  cold   (freezing),  71 

by  infiltration,  72 
lymphatism  and,  61 
precautions  during,  59 
selection  of  anesthetic  in,  61 
sequelae  of: 
burns,  70 
conjunctivitis,  69 
paralysis,  70 
pneumonia,  70 
soreness  of  jaw,  69 
soreness  of  tongue,  69 
shock  and,  108 
Anesthetics,   varieties   of : 
chloroform,  63 
ether,  62 
ethyl  chlorid,  65 
nitrous-ether,  65 
nitrous  oxid,  64 
nitrous-oxygen-ether,   65 
Angioma,  cavernous,  342 
characteristics  of,  342 


678 


INDEX 


Angionia,  nevus  form  of,  341 

treatment  of,  342 
Ankle  and  toes,  affections  of: 

claw  foot,  671 

hallux  valgus,  672 

hallux  varus,  673 

hammer-toe,  674 

supernumerary  toe,  671 

tuberculosis,  669 
Anus,  absence  of,  518 
Anus  and  rectum,  diseases  of: 

fissure  of  the  anus,  526 

imperf oration,  517 

perianal  abscess,  527 

polypus  of  rectum,  525 

prolapse  of  the  rectum,  521 
Appendectomy,  509 
Appendicitis,  33 

abscess  with,  510 

after-treament  of,  511 

anatomy  of,  499 

complications  of,  in  other  organs, 
502 

etiology  of,  499 

diagnosis  of,  504 

indigestion  and,  504 

intestinal  obstruction  and,  505 

intussusception  and,  505 

operation  for,  509 

peritonitis  and,  511 

pneumonia  and,  505 

posture  in,  22 

prognosis  in,  508 

symptoms  of,  503 

treatment  of,  506 

tuberculous  peritonitis  and,  505 

typhoid  and,  505 
Arsenic  as  a  tonic,  100 
Arterial  sclerosis,  limping  due  to,  25 
Arthritis  tiiberculosa  sicca,  205 
Ataxia,  264,  267 
Atrophy  following  poliomyelitis,  304 

Babinski's  sign,  265 
Bacterial  vaccines,  235 
Balanitis,  45,  535 


Bardenheuer's     method      (phalangeal 

tuberculosis),  596 
Bassini  operation  (hernia),  487 
"Bat-ears,"  362 
Bathing,    preparation    for   operation 

and,  79 
Beck's    operation    for    hypospadias, 

555 

Bell's  paralysis,  318 
Bevan's  operation  for  misplaced  tes- 
ticle, 545 

Bier's  hyperemia  method,  196,  204 
"Bilious    attacks,"   and   appendicitis, 

34 

Birthmarks,  364 
Birth  palsy,  308 
Bladder,  diseases  involving: 

calculi,  531 

emiresis,  529 

exstrophy,  489-491 

tumors,  534 
"Bleeders,"  112 
Blood,  abnormal  conditions  of,  50 

color  index  of,  49 

condition  of,  77 

count  of,  49 

examination  of,  46 
Bloodless  reduction  methods   in   hip 
dislocation,  608 

complications  of,  610 

fixation  in,  609 
von   Bokay,    Dr.,    on    hydrocephalus. 

358 

Bone  disease  and  limping,  24 
Bone  grafts,  living,  182 
Bone  tumors,  325 
Bowel  function  after  operation,  92 
Bradford  and  Lovett,  on  Pott's  dis- 
ease, 464 
Bradford    and    Lovett's    knee   brace, 

637,  641 

Bradford-Lovett    frame    (Pott's   dis- 
ease), 460 

Brain  and  its  membranes,  injury  of, 
compression  as  an,  282 
concussion  as  an,  281 


INDEX 


079 


Brain  and  its  membranes,  injury  of, 
contusions  as,  284 
convulsions  from,  279 
headache  from,  279 
muscular  contraction  from,  280 
paralysis  due  to,  280 
symptoms  of,  277 
vomiting  from,  278 
wounds  as,  284 

Bronchial  fibro-chondromata,  405 
Bronchial  fistula?,  clinical  character- 
istics of,  404 
etiology  of,  403 
treatment  of,  405 
Bucknall's    operation    for    hypospa- 

dias,  557 
Burns    and    scalds,    cicatrices    from, 

244 

diagnosis  of,  241 
following  anesthesia,  70 
general  considerations  of,  237 
prognosis  in,  242 
results  of,  238 
skin-grafting  after,  245 
treatment  of,  242 
X-ray,  241 

Calcium,  in  rickets,  130 
Calculus,  44 

Calmette's  ophthalmo-reaction,   191 
Calot  jacket   (Pott's  disease),  461 
Carcinoma,  characteristics  and  path- 
ology of,  336 

diagnosis  of,  338 

prognosis  in,  339 

treatment  of,  339 
Caries  sicca,  564 
"Carrying  angle"  of  arm,  574 
Cephalhematoma,  diagnosis  of,  359 

pathology  of,  359 

treatment  of,  360 
Cerebral  abscess,  diagnosis  of,  291 

etiology  of,  287 

prognosis  in,  292 

symptoms  of,  288 

treatment  of,  292 


Cei-ebral    paralysis,    infantile,    natal, 
313 

postnatal,  314 

prenatal,  312 
Cerebrospinal  fluid,  275 
Cervical  ribs,  supernumerary,  416 
Chapin  urinal,  82 
Chest,  examination  of,  81 
Chewing-gum  recommended,  163 
Child  and  adult,  differences  between, 

7 
Chloroform,  convenient  container  for, 

63 

Cicatricial  stenosis  of  the  esophagus, 
clinical  course  of,  412 

diagnosis  of,  413 

treatment  of,  413 
Circumcision,  536 

Clavicle,  fracture  of,  etiology  of,  563 
symptoms  of,  563 
treatment  of,  564 
Claw  foot,  671 
"Claw  toe"  in  pes  cavus,  662 
Cleft  palate,  after-treatment  of,  382 

etiology  and  pathology  of,  375 

Lane  operation  for,  377 

treatment  of,  377 
Cleft-sternum,  415 
Club  foot,  acquired,  659 

etiology  of,  651 

Hgamentous,  652 

Monod's  classification  of,  652 

muscular,  652 

operations  for,  655 

osseous,  653 

paralytic,  659 

pathological  anatomy  of,  652 

prognosis  in,  654 

symptoms  of,  654 

Taylor's  shoe  for,  658 

treatment  of,  654 

Willard's  method  with,  654 
Clubbed  thumb,  603 
Cocain,  72 
Cod  liver  oil,  100 

rickets  and,  119 


680 


INDEX 


Cold,  shock  from,  108 
Colon,    congenital    idiopathic    dilata- 
tion of,  etiology  of,  516 

symptoms  of,  516 

treatment  of,  517 
Color  index  of  blood,  49 
Compression  of  the  brain,  282 
Concussion  of  the  brain,  281 
Confidence  of  child,  gaining,  18 
Congenital  cysts  of  the  neck,  406 

bronchial,  407 

dermoid,  408 

lymphatic,  406 
Congenital  grooves,  562 
Congenital  surgical  conditions,  12 
Conjunctivitis    following    anesthesia, 

69 

Convalescence,  postoperative,  99 
Convulsive   seizures,   onset   of   acute 
diseases  and,  6 

reason  why  infants  are  free  from,  5 
Coxa  valga,  diagnosis  of,  614 

etiology  of,  614 

symptoms  of,  614 

treatment  of,  615 
Coxa  vara,  diagnosis  of,  613 

etiology  and  pathology  of,  612 

prognosis  in,  613 

symptoms  of,  613 

treatment  of,  614 
"Coxa  vara  traumatica,"  629 
Coxalgia,  615 
"Cranial  spina  bifida,"  353 
Craniotabes,  124 
Cricothyroid  membrane,  388 
Crile's  intubation  anesthesia,  65 
Cryptorchidism,  542 
Curvature  of  the  spine: 

general  considerations,  429 

kyphosis,  431 

lordosis,  436 
Cushing's  method  in  •  hydrocephalus, 

359 

Cystic  kidney,  congenital,  346 
Cystitis,  45 
Cystoma,  345 


De  Garmo-Hood  truss,  483 

Defecation,  painful,  44 

Dentary  cysts,  345 

Dentition,  16 

Dermoid  cysts  of  the  head,  charac- 
teristics of,  36 
diagnosis  of,  362 
treatment  of,  362 

Dermoids,  348 

Diaphragmatic  hernia,  congenital,  eti- 
ology of,  424 
location  of,   424. 
symptoms  of,  425 
treatment   of,  425 

Didot's  operation  for  syndactyly,  602 

Diet  after  operation,  89 

Digestive     disturbance,     preparation 
for  operation  and,  78 

Digestive     system,     acute    infections 
and,  6 

Dislocation  of  the  shoulder,  congeni- 
tal, 564 

Distention  of  bowels,  postoperative, 
92 

"Drop"     or    "Murphy"     method     of 
proctoclysis,  97 

Duplay's    operation    for    epispadias, 
551 

Dysuria,  44 

Ear,  affections  of: 

foreign  bodies  in  the  ear,  363 

malformations  of  external  ear,  362 

middle  ear  disease,  364 
Earache,  42 
Ectopia  testis,  542 
Ectopic  bladder,  489 
Ectromely,  561 

Eczema,  in  field  of  operation,  80 
Elbow,  anatomy  of,  570 

congenital  dislocation  of,  567 

fracture  of,  569 

tuberculosis  of,  567 
Emprosthotonus,  24 
Empyema,  after-treatment  of,  429 

bilateral,  429 


INDEX 


681 


Empyema,  diagnosis  of,  427 

etiology  of,  426 

prognosis  in,  427 

symptoms  of.  special  features  of, 
426 

treatment  of,  427 
Encephalocele,  diagnosis  of,  355 

operation  for,  355 

pathology  of,  354 

situation  of,  353 

symptoms  of,  354 

treatment  of,  355 

varieties  of,  353 
Enuresis,  calculi  and,  531 

diagnosis  of,  530 

frequency  of,  530 

Jaboulay's  treatment  of,  530 

symptoms  of,  529 

treatment  of,  530 
Eosinophilia,  54 
Epispadias,  pathology  of,  549 

symptoms  of,  550 

treatment  of,  550 
Epulis,  322 
Erb's  paralysis,  diagnosis  of,  310 

etiology  of,  309 

pathology  of,  309 

prognosis  in,  311 

treatment  of,  312 
Erysipelas,  diagnosis  of,  212 

erythema  and,  212 

etiology  of,  208 

incubation  of,  209 

prognosis  in,  212 

secondary,  210 

symptoms  of,  209 

treatment  of,  213 
Esmarch  bandage,  85 
Esophagus,    anatomical    peculiarities 
of,  410 

foreign  bodies  in,  410 

malformations  of,  409 

stenosis   of,   cicatricial,  412 

congenital,  410 
Ether,  62 
Ethyl  chlorid,  65 


Etrodactyly,   602 

Eucain,  73 

Exaggeration,  absence  of,  in  infants, 

8 
Examination,  age  in,  11 

general  considerations  in,  10 

history  of  pi-esent  illness  in,  13 

history  of  the  previous  conditions 
and,  15 

history  taking  in,  12 
Exomphalocele,  471 
Expression   of   disease   in   the  young 

child,  4 

Exstrophy    of    the    bladder,    clinical 
course  of,  490 

etiology  of,  489 

operative  relief  of,  491 

symptoms  of,  490 

treatment  of,  490 
Extremities,  absence  of,  561 

malformations  of,  561 

Face  affections: 
dermoid  cysts,  369 
lymphangioma,  367 
vascular  nevus,  364 
Facial  paralysis,  318 
"False  paralysis,"  259 
Fat     assimilation,     rickets     and, 

117 
Female    genitals,    malformations    of, 

559 

Femoral  or  crural  hernia,  489 
Femur,  fracture  of  neck  of,  diagnosis 

of,  629 

etiology  of,  628 
treatment  of,  629 
fracture  of  shaft  of,  diagnosis  of, 

631 

pathology  of,  630 
treatment  of,  631 

Fibula,  congenital  absence  of,   diag- 
nosis of,  648 
pathology  of,  648 
treatment  of,  648 
Volkman's  deformity  and,  648 


682 


INDEX 


Field   of   operation,   preparation  of, 

79 

Finsen  light,  tuberculosis  and,  195 
Fissure   of   the   anus,    symptoms   of, 
526 

treatment  of,  527 

Flat-foot,    anatomical    considerations 
of,  663 

diagnosis  of,  666 

examination  for,  665 

gymnastics  for,  668 

operative  treatment  for,  668 

precocious  walking  and,   665,   667 

prognosis  in,  667 

scoliosis  and,  441 

supports  for,  667 

symptoms  of,  665 

treatment  of,  667 

varieties  of,  665 
Foot,  deformities  of: 

club-foot,  650 

flat-foot,  663 

pes  cavus,  662 

talipes  calcaneus,  663 

talipes  equinus,  661 

varieties  of  (illustration),  661 
Forceps,    hemostatic    and    mosquito, 

85 
Forearm  and  hand,  affections  of: 

congenital  deviations  of  the  hand, 
597 

etrodactyly,  602 

fracture  of  radius,  593 

green-stick   fracture   of   the   fore- 
arm, 590 

injuries  of  the  hand,  598 

Madelung's  deformity,  593 

subluxation  of  the  head  of  the  ra- 
dius, 592 

syndactyly,  601 

tuberculosis  of  the  phalanges,  595 

tuberculosis  of  the  wrist,  594 

Volkmann's    ischemic    contracture, 

591 

"Forked  hand,"  603 
Formalin,  tuberculosis  and,  195 


Fowler     position     (after    appendec- 
tomy), 511 
Fracture,  of  the  elbow,  anatomy  of, 

570 

diagnosis  of,  573 
etiology  of,  572 

"gunstock"  deformity  after,  585 
"Jones  position"  for,  586 
operative  treatment  of,  589 
prognosis  in,  576 
special  indications   in   treatment 

of,  584 

treatment  of,  582 
typical  fonns  of,  578 
X-ray,  value  in,  575 
of  femur,  628 

of  lower  end  of  the  radius,  593 
of     skull,      see     Skull,     fractures 

of 

Fractures  in  children,  exuberant  cal- 
lus in,  248 

general  considerations  on,  246 
fever  in,  248 
in  the  newborn,  247 
incomplete  or  green-stick,  248 
intrapartum,  248 
of  clavicle,  250 
of  femur,  250,  255 
of  humerus,  249,  253,  258 
of  radius,  257 
of  tibia,  258 
peculiarities  of,  247 
separation    of    the    epiphyses    in, 

248,  252 

Fresh  air  and  sunshine,  in  convales- 
cence, 100 

Fungus  umbilici,  323         i 
Funnel  chest,  416 

Gag,  mouth,  378 
Gait,  limping,  24 

stumbling,  26 

waddling,  25 
Gavage,  101 
Genu  recurvatum,  642 


IXDEX 


083 


Genu  valgum,  age  of  occurrence  of, 
634 

operation  for,  638 

prognosis  in,  636 

symptoms  of,  635 

treatment  of,  636 
Genu  varum,  etiology  of,  639 

examination  for,  640 

prognosis  in,  640 

prophylaxis  of,  640 

symptoms  of,  639 

treatment  of,  640 

Gottstein  on  esophageal  stenosis,  414 
Grafts,  living  bone,  182 
Granulations,    sluggish    and    exuber- 
ant, 95 
Green-stick  fracture  of  the  forearm, 

590 

Grooves,  congenital,  562 
Gummata,  illustrations  of,  146,  147 
"Gunstock"  deformity  of  elbow,  585 
Gwathney  anesthesia  apparatus,  62 

Hallux  valgus,  diagnosis  of,  673 

etiology  of,  672 

pathology  of,  672 

symptoms  of,  673 

treatment  of,  673 
Hallux  varus,  673 
Hammer-toe,  674 
Hand,  congenital  deviations  of,  597 

injuries  of,  in  childhood,  598 
Harelip,  after-treatment  of,  374 

clinical  picture  of,  370 

operation  for,  372 

prognosis  in,  372 
Head,  affections  of: 

cephalhematoma,  359 

dermoid  cysts,  361 

encephalocele,  353 

fractures  of  the  skull,  360 

hydrocephalus,  congenital,  357 

microcephalus,  356 
Headache,  40 
Heart,  examination  of,  80 
Heat,  shock  from,  108 


Hedrocele,  522 

Hematemesis,   post-anesthetic,   68 
Hematomyelia,  269 
Hematuria  and  hemoglobinuria,  S3 
Hemimely,  561 

Hemophilia,  diagnosis  of,  113 
etiology  of,  112 

hemorrhagic   diseases   of  the    new- 
born and,  113 
operation  and,  76 
pathology  of,  113 
prognosis  of,  114 
symptomatology  of,  113 
transfusion  in,  115 
treatment  of,  114 
Hemorrhage,  constitutional  treatment 

of,  87 

control  of,  84 
delayed,  85 
primary,  85 
secondary,  87 
shock  and,  108 

Hemorrhagic  disease  of  the  newly 
born,  hemophilia  contrasted 
with,  12 

Hemostatic  forceps,  85 
Hermaphrodites,  554 
Hernia,  etiology  of,  470 
femoral  or  crural,  489 
inguinal,  475 
poliomyelitis  and,  305 
umbilical,  471 
Hibbs'  operation  for  Pott's  disease, 

462 

Hip,  congenital  dislocation  of,  diag- 
nosis of,  607 

etiology  and  pathology  of,  604 
Kirmisson's  method  in,  608 
Lorenz'    bloodless    reduction    of, 

608 

prognosis  in,  607 
symptoms  of,  606 
treatment  of,  607 

Hip  disease,  Pott's  disease  and,  454 
Hip  joint  disease,  complications  of, 
628 


684 


INDEX 


Hip  joint  disease,  diagnosis  of,  621 

differential  diagnosis  in,  624 

examination  in,  621 

pathology  of,  615 

prognosis  in,  625 

symptoms  of,  616 

treatment  of,  625 
Hirschsprung's  disease,  516 
History  card,  13 
Hollow  foot,  see  Pes  cavus 
Hutchinson's  teeth,  149 
Hydrocele,  diagnosis  of,  540 

normal  and  pathological  anatomy 
of,  539 

of  the  neck,  406 

symptoms;  of,  540 

treatment  of,  541 

varieties  of,  539 
Hydrocephalus,   congenital,  von  Bo- 

kay  on,  358 

Cushing's  method  in,  359 
pathology  of,  357 
treatment  of,  358 
Hydroencephalocele,  353 
Hypertrophied  tonsils,  383 
Hypospadias,    Beck's   operation   for, 
555 

Bucknall's  operation  for,  557 

clinical  varieties  of,  552 

functional  disturbances  from,  554 

pathology  of,  552 

Rochet's  operation  for,  556 

treatment  of,  554 

Imperforate  anus  and  rectum,  clini- 
cal picture  of,  518 
etiology  of,  517 
treatment  of,  519 
"Incontinence,  active,"  263 

of  urine,  see  Enuresis 
Incubation  periods,  75 
Infantile  cerebral  paralysis,  see  Ce- 
rebral paralysis 
Infection   of   wounds,   care     against, 

94 
Infiltration  anesthesia,  71,  72 


Inguinal  hernia,  complications  of, 
479 

differential  diagnosis  of,  478 

etiology  of,  477 

frequency  of,  476 

hydrocele  and,  478 

normal  and  pathological  anatomy 
of,  475 

pathology  of,  477 

radical  cure  of,  486 

reducible,  481 

site  of,  477 

strangulated,  479 

symptoms  of,  478 

treatment  of,  478 

truss  for,  482 
Intestinal  colic,  pain  in,  32 
Intestinal  disorders : 

congenital  idiopathic  dilatation  of 
colon,  516 

intussusception,  512 
Intracranial  tumors,  diagnosis  of,  296 

etiology  of,  292 

symptoms  of,  293 

Intradural  (spinal)  hemorrhage,  269 
Intubation,  389 
Intubation  anesthesia,  65 
Intussusception,  diagnosis  of,  514 

etiology  of,  512 

prognosis  in,  514 

symptoms  of,  513 

treatment  of,  515 
lodoform,  tuberculosis  and,  195 
Iron  tonics,  100 

Jaboulay's  serum  method  in  enure- 
sis,  530 

Jaundice,  hemorrhage  and,  78 

Jaw,  soreness  of,  following  anesthe- 
sia, 69 

"Jones  position"  in  fracture  of  el- 
bow, 586 

Keloids,  character  of,  349 
etiology  of,  323,  348 
prognosis  in,  349 


INDEX 


085 


Keloids,  symptoms  of,  349 

treatment  of,  350 
Kidney,  sarcoma  of,  diagnosis  of,  529 

etiology  of,  528 

prognosis  in,  529 

treatment  of,  529 

Kermisson,  method  of,  in  hip  dislo- 
cation, 608 

in  tuberculosis  of  shoulder,  566 
Klapp's    method   in   purulent   infec- 
tions, 234 
Knee,  affections  of: 

congenital  absence,  632 

congenital  dislocation,  632 

geuu  recurvatum,  642 

genu  valgum,  634 

genu  varum,  639 

injury  to  tubercle  of  tibia,  633 

tuberculosis,  643 
Kocher,  operation  (hernia),  487 
Kyphosis  of  Pott's  disease,  448 

postural,  432 

rachitic,  431 

Lane  operation  for  cleft  palate,  377 

Lannelongue  (on  microeephalus),  356 

Lavage,  104 

Laxative,   preparatory  to  operation, 
78 

Leary's  serum  method,  114 

Leg,    rachitic    curvatures    of,    opera- 
tion for,  647 
pathology  of,  646 
prophylaxis  against,  647 
treatment  of,  647 

Leiomyoma,  329 

Leukocytosis,  50 

Leukopenia,  54 

Limping,  24 

Lincoln  tuberculin  test,  201 

Lipoma,   325 

of  the  face  and  neck,  408  . 

Local     anesthesia,     see     Anesthesia, 
local 

Lockjaw,  see  Tetanus 

Lordosis,  436 


Lorenz'  bloodless  method  in  hip  dis- 
location, 608 
Lumbar  puncture,  270 
Lung,  congenital  hernia  of,  425 
Lymphangioma,  diagnosis  of,  343 

of  the  face,  367 

prognosis  in,  344 

treatment  of,  344 

varieties  of,  343 

Lymphatic  cysts  of  the  neck,  406 
Lymphatic  glands,   location   of,   163, 

364 
"Lymphatism,"  155 

and  anesthesia,  61 
Lymphocytosis,  54 
Lymphoma,  331 
Lymphosarcoma,  332 

MacEwen's    supracondyloid '  osteoto- 
my for  knock-knee,  638 
Macroglossia,  368 
Madelung's   deformity   of   the   wrist, 

593 
Malformations  of  the  female  genitals, 

559 
Malleolus,  structures  behind  internal, 

657 

Mastoiditis,  42 

Meckel's   diverticulum,   clinical  anat- 
omy of,  466 
diagnosis  of,  468 
treatment  of,  469 
umbilical  adenoma  and,  467 
umbilical  cysts  and,  467 
Meningocele,  353 
Mental  activity,  infantile  health  and, 

8 

Microeephalus,  356 
Milk  and  diet,  91 
rickets  and,  118 
Moles,  322 
Monod's    classification    of   club-foot, 

652 

Moro  tuberculin  reaction,  190 
Morphia,  in  operations,  99 
Mosetig's  iodoform  plug,  182 


686 


INDEX 


Mosquito  forceps,  85 

Mouth,    toilet    of,    preparation    for 

operation  and,  79 
Mouth  gag,  378 
Murphy  drip   (after  appendectomy), 

511 
"Murphy"     or     "drop"     method     of 

proctoclysis,   97 
Muscular    activity,    infantile    health 

and,  8 

Muscular  tone,  280 
Musculospiral  nerve  paralysis,  318 
Myelocystocele,  418 
Myelomeningocele,   418 
Myomata,  329 
Myxomata,  323 

Nasal  feeding,  104 

Nausea  and  vomiting,  post-anesthetic, 

67 
Neck,  affections  of: 

bronchial  fibrochondromata,  405 

bronchial  fistula?,  403 

congenital  cysts,  406 

dernioid  cysts,  408 

lipomas,  408 

torticollis,   congenital,   396 

tuberculous  glands,  399 
Needle-holder   (Lane),  379 
Neoplasms,  320 
Neuroepithelioma,  422 
Neuromata,  329 
Nevus,  341 

vascular,  diagnosis  of,  365 
pathology  of,  364 
prognosis  in,  365 
treatment  of,  366 
varieties  of,  365 
Nitrous  ether,  65 
Nitrous  oxid,  64 
Nitrous-oxygen-ether,  65 
Nose,  foreign  bodies  in,  370 
Novocain,  73 
Nuck,  canal  of,  hydrocele  of,  542 

Oakum  pillows,  89 


Occupation  scoliosis,  439 
Operating  room,  59 
Ophthalmo-reaction    (Calmette),   191 
Opisthotonos,  24 
Oral  affections : 
adenoid  vegetations,  383 
cleft  palate,  375 
foreign  bodies  in  the  nose,  370 
harelip,  370 

hypertrophied  tonsils,  383 
ranula,  383 

retropharyngeal  abscess,  385 
Orange  juice,  for  scorbutus,  136 
Osteomyelitis,  hip-joint   disease   and, 

624 

infective,  diagnosis  of,  178 
etiology  and  pathology  of,  175 
prognosis  in,  179 
rheumatism  and,  179 
symptoms  of,  177 
treatment  of,  179 
typhoid  and,  178 
primary  chronic,  183 
rarer  forms  of,  183 
Otitis,  42 

Pain,  267    ' 
and  sleep,  97 
character  of,  28 
onset  of,  27 
significance   of : 

in  abdomen,  31 

in  appendicitis,  33 

in      caseation       of      mesenterio 
glands,  40 

in  defecation,  painful,  44 

in  dysuria,  44 

in  earache,  42 

in  gastric  dilatation,  39,  40 

in  headache,  40 

in  intestinal  catarrh,  38 

in  intestinal  colic,  32 

in  intestinal  parasites,  38 

in  intussusception,  38 

in  lead  colic,  39 

in  lobar  pneumonia,  38 


INDEX 


68: 


Pain  in  movable  kidney,  39 
in  nephritic  colic,  39 
in  overdistended  bladder,  39 
in  peritonitis,  acute,  37 
in  rectal  tenesmus,  44 
in  rheumatic  fever,  39 
in  spinal  caries,  39 
in  strangulated  hernia,  39 
site  of,  28 
tenderness  and,  27 
time  of  occurrence  of,  27 
Paracoccygeal  fistula?,  424 
Paralyses  of  childhood : 
Erb's  paralysis,  308 
facial  paralysis,  318 
infantile  cerebral  paralysis,  312 
musculospiral  nerve  paralysis,  318 
poliomyelitis,  acute,  298 
pressure  paralysis,  317 
sympathetic  nerve  paralysis,  319 
Paralysis,  brain  injuries  and,  280 
clinical  manifestations  of,  260 
corticospinal,  261 
following  anesthesia,  70 
general  character  of,  262 
general  consideration  of,  259 
infantile     cerebral,     see     Cerebral 

paralysis,  infantile 
monoplegia  and,  260 
pressure,  see  Pressure  paralysis 
spinomuscular,  261 
Paraplegia,   Pott's,  463 
Patella,  congenital  dislocation  of,  632 
Pediatric  surgeon,  qualifications  of,  3 
Perianal  abscess,  symptoms  of,  527 

treatment  of,  528 
Perinephritis,  posture  in,  23 
Periostitis   albuminosa,  183 
Peritonitis,  acute,  37 
pain  in,  32 
pneumococcus,    clinical    forms    of, 

497 

diagnosis  of,  498 
etiology  of,  497 
symptoms  of,  498 
treatment  of,  499 


Peritonitis,  posture  in,  22 

tuberculous,  clinical  forms  of,  495 
diagnosis  of,  496 
etiology  of,  494 
symptoms  of,  495 
treatment  of,  496 
Pertussis,  and  operation,  76 
Pes  cavus,  662 

Phalanges,  tuberculosis  of,  595 
Pharynx     and     esophagus,     foreign 

bodies  in,  410 

Phimosis  and  pharaphimosis,  circum- 
cision for,  536 
clinical  course  of,  535 
etiology  of,  536 
paraphimosis,  538 
treatment  of,  536 
Phlegmons  of  back,  posture  in,  24 
Phosphorus,  in  rickets,  129 
Pho3omely,  561 
Pigeon-breast,  415 
von  Pirquet's  tuberculin  test,  189 
Plaster  jackets    (in   Pott's   disease), 

459 

Pleurisy,  posture  in,  21,  23 
Pneumococcus  peritonitis,    see    Peri- 
tonitis, pneumococcus 
Pneumonia,  following  anesthesia,  70 
Poliomyelitis,  acute,  age  incidence  of, 

298 

diagnosis  of,  302 
mechanical  and  operative  treat- 
ment of,  308 
multiple  neuritis  and,  306 
muscular  dystrophy  and,  306 
prognosis  in,  307 
pseudoparalysis  and,  306 
seasonal  incidence  of,  299 
symptoms  of,  300 
transverse  myelitis  and,  306 
"Polypi,  auditory  or  aural,"  323 
Polypus  of  rectum,  525 
"Port  wine"  mark,  364 
Post-anesthetic  care  in  hematemesis, 
68 


688 


INDEX 


Post-anesthetic   care   in   nausea   and 
vomiting,  67 

in  restlessness,  undue,  68 

in  sweating,  68 

in  thirst,  68 
Post-operative  care,  88 

of  bowel  function,  92 

of  diet,  89 

of  room,  89 

of  wound,  93 
Posture,  faulty  and  correct,  434 

general,   21 : 
abdominal,  23 
changing  position,  24 
dorsal  position,  22 
forced  positions,  24 
side  position,  21 
upright  positions,  24 
Pott's  disease,  abscesses  in,  452,  463 

braces  in,  461 

Bradford  and  Lovett  frame  in,  460 

Bradford  and  Lovett  on,  464 

Calot  jacket  in,  461 

clinical  picture  of,  446 

complications  of,  463 

diagnosis  of,  453 

differential  diagnosis  of,  454 

examination  of  patient  in,  452 

of  the  lumbar  spine,  hip-joint  dis- 
ease and,  624 

operative  treatment  of,  462 

paralysis  in,  449,  452 

paraplegia  from,  463 

plaster  jackets  in,  459 

posture  in,  24 

prognosis  in,  455 

suboccipital,  464 

symptoms  of,  449 

Taylor  brace  in,  458 

treatment  of,  455 

Whitman-Bradford  frame  for,  456 
Precocious  walking  and  flat-foot,  665 
Preparation  for  operation,  74: 

examination  of  patient,  80 

field  of  operation,  79 

preparation  of  patient,  75 


Pressure  paralysis,  317 

Proctoclysis,  96 

Prolapse  of  the  rectum,  diagnosis  of, 

522 

partial  and  total,  521 
prognosis  in,  523 
symptoms  of,  522 
treatment  of,  523 

Psychic  influences  upon  infantile  dis- 
ease, 5 

Pupils  during  anesthesia,  GO 
Purulent  infections  of  the  skin  and 
subcutaneous  tissues,  abscesses 
as,  234 

furuncles  as,  233 
phlegmons  as,  234 
Pyemia,  complications  of,   231 
diagnosis  of,  231 
etiology  of,  230 
symptoms  of,  230 
treatment  of,  231 

Pylorus,  congenital  hypertrophic  ste- 
nosis of,  normal  and  patholog- 
ical anatomy  of,  492 
occurrence  of,  493 
symptoms  of,  493 
treatment  of,  494 
Pyuria,  84 

"Quiet  necrosis,"  183 
Quinin  and  urea,  infiltration  anesthe- 
sia with,  73 

Rachitic  skull,  16 

Rachitis,  see  Rickets 

Radium,  in  nevus,  366 

Radius,  subluxation  of  the  head  of, 

592 

Ranula,  383 
Rectal  feeding,  104 
Rectum,  polypus  of,  525 
Reflexes,  disturbance  of,  264 
Respiration  of  infants,  chart  of.  11 
Retention  cysts,  diagnosis  of,  347 

etiology  of,  345 

hydronephrosis  as,  347 

treatment  of,  347 


INDEX 


089 


Retropharyngeal  abscess,  385 
Rhabdomyoma,  329 
Rheumatism,  limping  and,  24 

scorbutus  and,  135 
Rib,  resection  of,  for  empyema,  427 
Rickets,  abdomen  in,  124 

age  incidence  of,  120 

anemia  and,  120 

bone  changes  in,  124 

calcium  in,  130 

chest  in,  123 

constipation  in,  121 

convulsive  seizures  and,  125 

cranial  contours  in,  127 

craniotabes  in,  124 

dentition  and,  121 

diagnosis  of,  126 

diet  and,  117 

digestive  system  in,  125 

epiphyseal  thickening  in,  122 

"girdle"  in,  125 

head  in,  123 

muscular  flabbiness  in,  121 

nervous  symptoms  in,  125 

phosphorus  in,  129 

respiratory  organs  in,  125 

"rosary"  in,  122 

symptoms  of,  120 

syphilis  and,  127 

treatment  of,  128 

waddling  and,  26 
Rochet's  operation  for  hypospad 

556 

Room  for  post-operative  care,  89 
Round  shoulders,  432 

Saber-like  tibia,  148 
"Saber-shin,"  647 

Sacrococcygeal    tumors,      congenital, 
diagnosis  of,  423 

etiology  and  pathology  of,  421 

situation  of,  422 

symptoms  of,  423 

treatment  of,  423 

Sacroiliac  joint,  tuberculosis  of,  4G4 
Saline  infusion,  96 


Salivary  calculi  simulating    adenitis, 

161 

Salvarsan,  155 
Sapremia,  etiology  of,  231 

symptoms  and  diagnosis  of,  232 

treatment  of,  233 
Sarcoma,  331 

character  and  growth  of,  334 

diagnosis  of,  335 

occurrence  of,  334 

of  the  kidney,  528 

of  the  testicles,  549 

pathology  of,  333 

Pott's  disease  and,  454 

treatment  of,  335 

varieties  of,  331 
Scalds,  see  Burns 

Scapula,  congenital  elevation  of,  clin- 
ical picture  of,  562 

etiology  of,  563 

treatment  of,  563 

Scoliosis,  etiology  and  pathology  of, 
438 

general  considerations  of,  437 

pathological  anatomy  of,  439 

prognosis  in,  442 

prophylaxis  against,  442 

rachitic,  446 

symptoms  of,  440 

treatment  of,  443 
Scorbutus,   age  incidence  in,  130 

diagnosis  of,  135 

etiology  of,  131 

pain  in,  28 

pathology  of,  132 

posture  in,  23 

prognosis  in,  135 

prophylaxis  and  treatment  of,  136 

rheumatism  and,  135 

symptomatology  of,  132 ' 
Scrofulosis,  184 
Scurvy,  see  Scorbutus 
"Scurvy  rickets,"  128 
Sensory   disturbances,  266 
Septic  diseases  in  general,  226 
Septic  intoxication,  227 


690 


INDEX 


Septic  thrombosis,  285 
Septiceraia,  prognosis  in,  230 

symptoms  of,  229 

treatment  of,  230 
Shock,  anemia  and,  109 

anesthesia  and,  108 

cold  and,  108 

diagnosis  of,  106 

etiology  of,  107 

fear  and,  109 

heat  and,  108 

hemorrhage  and,  108 

operation,  duration  of,  and,  108 

treatment  of,  109 
Shoulder,  affections  of: 

congenital  dislocation,  564 

congenital  elevation  of  the  scapula, 
562 

fracture  of  the  clavicle,  563 

tuberculosis,  564 
Sinus  phlebitis,  285 
Skin  and  subcutaneous  tissues,  puru- 
lent  infections   of,   see  Puru- 
lent infections 

Skull,  fractures  of,  prognosis  in,  360 
symptomatology  of,  360 
treatment  of,  361 

rachitic,  16 
Sleep  and  pain,  97 
Sphincter  control,  disturbance  of,  263 
Spina  bifida,  anatomical  classification 
of,  418 

diagnosis  of,  419 

location  of,  417 

occulta,  420 

operation  for,  420 

prognosis  in,  419 

symptoms  of,  418 

treatment  of,  419 
"Spina  Ventosa,"  199,  201 
Spinal  column,  evolution  of,  430 
Spinal  concussion,  268 
Spinal  contusion  and  laceration,  268 
Spinal  cord,  injuries  and  disease  of, 

259 
ataxia  from,  264 


Spinal  cord,  Babinski's  sign  in,  265 
disturbance  of  sphincter  control 

from,  263 

disturbance  of  reflexes  by,  264 
pain  in,  267 
paralysis  from,  259 
sensory  disturbances  due  to,  266 
vasomotor   and   trophic   disturb- 
ances from,  267 
nature  of  injuries  of,  268 
Spinal  disease,  posture  in,  23 
Spinal  meningocele,  418 
Spine,  curvature  of,  see  Curvature  of 

the  spine 

demonstrating  flexibility  of,  453 
tuberculosis  of,   see  Pott's  disease 
SpirochaBta  pallida,   151 
Spitzy's   method   in   fracture   of   the 

Immerus,  249 
Spitzy's     paraffin     injection     (rectal 

prolapse),    524 

Spitzy's  pathognomonic  sign  (tuber- 
culosis of  sacroiliac  joint), 
465 

"Spoiled   child,"   examination   of,   21 
Spondylitis,  traumatic,  Pott's  disease 

and,  455 

Status  lymphaticus,  diagnosis  of,  157 
"lymphatism"  and,  155 
pathology  of,  155 
symptoms  of,  156 
thymus  and,  155 
tuberculosis  and,  184 
Sternum,  absence  of,  415 
Stimulants   or   tonics   during   conva- 
lescence,  100 

Stomach,  rickets  and,  120 
Stomach  washing,  102 
Stumbling  gait,  26 
Sunshine  and  fresh  air  in  convales- 
cence, 100 
Supracondylar    fracture,    of    elbow, 

579 

Sweating,  post-anesthetic,  68 
Sympathetic  nerve  paralysis,  319 


INDEX 


691 


Symptomatology   in    infants,   consti- 
tutionality of,  6 
Syndactyly,  601 
Syphilis,  acquired,  138 

congenital,  diagnosis  of,  150 
etiology  of,  140 
family  history  of,  151 
Hutchinson's  teeth  and,  149 
"inherited"  and,  139 
pathology  of,  141 
prognosis  in,  152 
salvarsan  in,  155 
symptoms  of,  142 
treatment  of,  152 
types  of,  141 

"Wassermann  reaction  in,  152 
effects  of,  on  infant,  16,  17 
rickets  and,  127 
Syphilitic  adenitis,  167 
Syphilitic   bone   infections,    tubercu- 
losis distinguished  from,  202 

Tactile  anesthesia,  267 
Talipes  calcaneus,  663 
Talipes  equinovarus,  see  Club-foot 
Talipes  equinus,  acquired,  661 
pathology  of,  661 
symptoms  of,  661 
treatment  of,  662 
Tarsectomy  for  club-foot,  658 
Taylor  brace  (Pott's  disease),  458 
Taylor  club-foot  shoe,  658 
Taylor  hip-splint,  627 
Teeth,  appearance  of,  16 
Tenderness,  27 
Tenosynovitis,  posture  in,  23 
Teratomata,  340 
Testicle,  misplaced,  complications  of, 

543 

operation  for,  545 
prognosis  in,  543 
symptoms  of,  543 
treatment  of,  544 
Testis,  diseases  of: 
hydrocele,  539 
sarcoma,  549 


Testis,  diseases  of: 
tuberculosis,  547 
undescended  and  misplaced  testicle, 

542 

Tetanus,  antitoxin  in,  221 
chronic,  216 
clinical  forms  of,  215 
etiology  of,  214 
facial,  216 

hydrophobia  and,  218 
meningitis  and,  218 
neonatorum,   215 
prognosis  in,  219 
strychnin  poisoning  and,  218 
symptomatology  and  diagnosis  of, 

216 

traumatica,  216 
treatment  of,  220 
Thermoanalgesia,  266 
Thirst,  post-anesthetic,  68 

significance  and  relief  of,  95 
Thorax  and  spine,  affections  of: 
congenital     hernia     of     the     lung, 

425 

curvature  of  the  spine,  429 
diaphragmatic    hernia,    congenital, 

424 

empyema,  426 

malformations  of  the  thorax,  415 
paracoccygeal  fistulse,  424 
Pott's  disease,  446 
sacrococcygeal   tumors,    congenital, 

421 

spina  bifida,  417 
supernumerary  cervical  ribs,  416 
tuberculosis  of  the  sacroiliac  joint, 

464 

tuberculosis  of  the  spine,  446 
Thrombosis  of  the  sinus  of  the  dura 

mater,    course    and    prognosis 

in,  286 

etiology  of,  285 
site  of,  285 
symptoms  of,  285 
treatment  of,  287 
Thymus,  status  lymphaticus  and,  155 


692 


INDEX 


Tibia,  congenital  absence  of,  pathol- 
ogy of,  649 
prognosis  in,  650 
treatment  of,  650 
injury  of  the  tubercle  of,  633 
removal  of  part  of,  18] 
Tibia  and  fibula,  affections  of,  646 
Toe,  supernumerary,  671 
Tongue,  soreness  of,  following  anes- 
thesia, 69 

Tonics  or  stimulants  during  conval- 
escence, 100 

Tonsils,  hypertrophied,  383 
Torticollis,    congenital,   diagnosis   of, 

397 

etiology  of,  396 
pathology  of,  396 
Pott's    disease   and,   454 
symptoms  of,  397 
treatment  of,  398 
Tracheal  cannula,  394,  395 
Tracheotomy,  392 
Transfusion,  after  hemorrhage,  88 

in  hemophilia,  114 
Trochanteric    bursitis    and    hip-joint 

disease,  624 
Truss  for  hernia,  482 
Tubercles,  185 

Tuberculin,  Lincoln  test  with,  201 
Tuberculin  tests: 

cutaneous  (Von  Pirquet),  189 

Moro  reaction,  190 

ophthalmo  -  reaction      (Calmette), 

191 

subcutaneous,  188 
Tuberculosis  of  ankle, 
pathology  of,  669 
prognosis  in,  670 
symptoms  of,  669 
treatment  of,  670 
of  bones,  diagnosis  of,  201 
etiology  and  pathology  of,  199 
operation  indicated  in,  204 
prognosis  in,  203,  206 
symptoms  of,  200 
syphilis  distinguished  from,  202 


Tuberculosis  of  bones,  treatment  of, 

203 
of  elbow,  diagnosis  of,  568 

pathology  of,  567 

symptoms  of,  567 

treatment  of,  568 
of  hip,  615 
of  joints,  pathology  of,  205 

prognosis  in,  206 

symptoms  of,  206 

treatment  of,  207 
of  knee,  diagnosis  of,  644 

pathology  of,  643 

prognosis  in,  645 

symptoms  of,  644 

treatment  of,  645 
of  phalanges,  595 
of  sacroiliac  joint,  464 
of  shoulder,  diagnosis  of,  566 

pathology  of,  564 

prognosis  in,  566 

symptoms  of,  565 

treatment  of,  566 
of  spine,  see  Pott's  disease 
of  testicle,  clinical  picture  of,  547 

diagnosis  of,  548 

treatment  of,  548 
of  wrist,  594 

etiology  of,  594 

prognosis  in,  595 

symptoms  of,  594 

treatment  of,  595 
surgical,  age  and,  186 

clinical  diagnosis  of,  188 

clinical  manifestations  of,  187 

environment  and,  186 

etiology  of,  184 

heredity  and,  185 

local  treatment  of,  195 

lymphatism  and,  184 

operative  treatment  of,  195 

predisposition    of    previous    dis- 
ease to,  187 

racial  predisposition  to,  187 

scrofulosis  and,  184 

traumatic  predisposition  to,  187 


INDEX 


Tuberculosis,    surgical   treatment    of, 

191 

tubercle  bacillus  and,  184 
tubercular  diathesis  and,  186 
tuberculin  tests  for,  188 
tuberculin  treatment  of,  198 
Tuberculous    adenitis,    diagnosis    of, 

172 

etiology  of,  168 
lesions  of,  169 
prognosis  in,  173 
symptoms  of,  170 
treatment  of,  173 

Tuberculous  glands  of  the  neck,  399 
anatomical  considerations,  399 
diagnosis  of,  401 
method  of  invasion  of,  399 
symptoms  of,  400 
treatment  of,  402 
Tuberculous      peritonitis,     flatulence 

and  incipient,  33 
Tubulodermoids,  348 
Tumor  albus,  643 
Tumors  in  children : 
angioma,  341 

benign  and  malignant,  321 
bone,  325 
carcinoma,   336 
cystoma,  345 
dermoids,  348 
fibromata,  322 
general  considerations,  320 
keloids,  349 
lipoma,  325 
lymphangioma,  343 
lymphoma,  331 
myomata,  329 
myxomata,  323 
neuromata,  329 
osteomata,  327 
retention  cysts,  345 
sarcoma,  331 
teratomata,  340 
varieties,  322 
intracranial,  see  Intracranial 

tumors 
and  headache,  40 


Tumors   in  children : 

of  the  bladder,  534 
Umbilical  hernia,  etiology  of,  471 

pathology  of,  471 

symptoms  of,  472 

treatment  of,  472 
Undescended  testicle,  542 
Urea    and    quinin,    infiltration    anes- 
thesia with,  73 
Urinals,  82 
Urine,  examination  of,  83 

securing  specimen  of,  77 

Vaccination  and  operation,  76 
Vaccines,  bacterial,  235 
Van   Cott's   combined  bacterial   vac- 
cine, 236 
Vasomotor  and  trophic  disturbances, 

267 

Vein,  method  of  puncture  of,  53 
Vesical  calculi,  diagnosis  of,  533 

etiology  of,  531 

examination  for,  532 

symptoms  of.  531 

treatment  of,  533 
Volkmann's  deformity,  648 
Volkmann's  ischemic  eontracture,  591 
Vomiting,  postoperative,  93 

Waddling,  25 

Walking,    precocious,    and    flat-foot, 

665 

Water  drinking,  preparation  for,  78 
White  swelling,  205 

of  knee,  643 
Whitman's  method  in  fracture  of  the 

femur,  630 
Whitman-Bradford     frame      (Pott's 

disease),  456 

Willard's  method  with  club-foot,  655 
Wound,  postoperative  care  of,  93 
Wrist,    spontaneous    subluxation    of, 

593 
Wry  neck,  see  Torticollis 

X-ray,  burns  from,  241 
diagnostic  value  of,  55 
in  nevus,  366 
tuberculosis  and,  195 


A  000  432  587  4 


WS200 
C192s 
1912 

Campbell,  William  F 

Surgical  diseases  of  children 


WS200 
C192s 
1912 
Campbell,  William  F 

Surgical  diseases  of  children. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


